| Elmer G Dodge Jr, FNP | |
|
9858 W State St, Star, ID 83669-5210 | |
| (208) 286-0666 | |
| (208) 286-0565 |
| Full Name | Elmer G Dodge Jr |
|---|---|
| Gender | Male |
| Speciality | Nurse Practitioner |
| Location | 9858 W State St, Star, Idaho |
| Accepts Medicare Assignments | Medicare enrolled and may accept medicare through third-party reassignment. May prescribe medicare part D drugs. |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1508918236 | NPI | - | NPPES |
| NPQP7 | Other | ID | BLUE CROSS OF IDAHO |
| 000010150031 | Other | ID | REGENCE BLUE SHIELD OF ID |
| 806045400 | Medicaid | ID |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 163WG0000X | Registered Nurse - General Practice | NP534A (Idaho) | Secondary |
| 363L00000X | Nurse Practitioner | NP-534A (Idaho) | Primary |
| Entity Name | Walter Knox Memorial Hospital |
|---|---|
| Entity Type | Part B Supplier - Clinic/group Practice |
| Entity Identifiers | NPI Number: 1063419018 PECOS PAC ID: 7012907785 Enrollment ID: O20040514000512 |
| Entity Name | Black Canyon Medical Group Pllc |
|---|---|
| Entity Type | Part B Supplier - Clinic/group Practice |
| Entity Identifiers | NPI Number: 1811419708 PECOS PAC ID: 8123393071 Enrollment ID: O20171003007502 |
| Mailing Address | Practice Location Address |
|---|---|
| Elmer G Dodge Jr, FNP Po Box 44267, Boise, ID 83711-0267 Ph: (208) 286-0666 | Elmer G Dodge Jr, FNP 9858 W State St, Star, ID 83669-5210 Ph: (208) 286-0666 |
Mrs. Erica Jo Wright, NP-C Nurse Practitioner Medicare: Accepting Medicare Assignments Practice Location: 10542 W Stonecrop Dr, Star, ID 83669 Phone: 208-830-1368 | |
Elena Jacobs, Nurse Practitioner Medicare: Medicare Enrolled Practice Location: 9858 W State St, Star, ID 83669 Phone: 208-286-9471 | |
Erika Johnstone, PMHNP-BC Nurse Practitioner Medicare: Not Enrolled in Medicare Practice Location: 307 S Long Bay Way, Star, ID 83669 Phone: 425-802-7193 | |
Sherry Lynn Stanton, NP Nurse Practitioner Medicare: Accepting Medicare Assignments Practice Location: 9858 W State St, Star, ID 83669 Phone: 208-286-9471 Fax: 208-286-0565 | |
Kayla Marie Woods, FNP-C Nurse Practitioner Medicare: Not Enrolled in Medicare Practice Location: 2500 N Lithodora Ave, Star, ID 83669 Phone: 559-356-6696 |