William Mark Imus Jr., FNP

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

NP57A Issued in ID

Practice address

610 NW 2ND St
Grangeville, ID 83530-1244

Phone

(208) 983-5120

Fax

(208) 983-5404

NPI assigned

Jul 4, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Physician'S Primary Care Center, Inc.

  • Basic Emergency Medical Technician
  • Weiser, ID
  • NPI 1922291384
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151971200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1247011200000",
    "number": "1902836802",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "610 NW 2ND ST",
            "city": "GRANGEVILLE",
            "state": "ID",
            "postal_code": "835301244",
            "telephone_number": "208-983-5120",
            "fax_number": "208-983-5404"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "610 NW 2ND ST",
            "city": "GRANGEVILLE",
            "state": "ID",
            "postal_code": "835301244",
            "telephone_number": "208-983-5120",
            "fax_number": "208-983-5404"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "IMUS",
        "first_name": "WILLIAM",
        "middle_name": "MARK",
        "name_suffix": "Jr.",
        "credential": "FNP",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-04",
        "last_updated": "2009-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "ID",
            "license": "NP57A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "804251600",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF IDAHO",
            "identifier": "NPWD6",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BLUE SHIELD",
            "identifier": "000010152061",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Idaho County Dermatology, PLLC
• Idaho Dept of Health & Welfare Reg 2 Amh
• Idaho Dept of Health & Welfare Reg 2 CMH
• Idaho Dept of Health & Welfare Reg II Amh Grangeville
• Idaho Dept of Health & Welfare Reg II CMH Grangeville
• Irwin Drug Inc.
• Jill M Lane LLC
• Chad Guy Jungert, RPH
• Tricia Klement
• Christina L. Koehler, L.M.P.

• Nurse Practitioner in Grangeville, ID
• Providers in Grangeville, ID by specialty
• Nurse Practitioner in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.