Individual
WILLIAM MARK IMUS JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
FNP
Contact information
Practice address
610 NW 2ND ST, GRANGEVILLE, ID 83530-1244
(208) 983-5120
(208) 983-5404
Mailing address
610 NW 2ND ST, GRANGEVILLE, ID 83530-1244
(208) 983-5120
(208) 983-5404
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
NP57A
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010152061
REGENCE BLUE SHIELD
ID
05
—
804251600
—
ID
01
—
NPWD6
BLUE CROSS OF IDAHO
ID
Enumeration date
07/04/2006
Last updated
07/08/2009
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