| Family Practice By The Lake Llc | |
|
1875 N Lakewood Dr Ste 205 Coeur D Alene ID 83814-4928 | |
| (208) 966-4087 | |
| (208) 966-4031 |
| Full Name | Family Practice By The Lake Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 1875 N Lakewood Dr Ste 205, Coeur D Alene, Idaho |
| Authorized Official Name and Position | Jacqueline Lee Wagner (OWNER) |
| Authorized Official Contact | 2086611181 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Family Practice By The Lake Llc 1875 N Lakewood Dr Ste 205 Coeur D Alene ID 83814-4928 Ph: (208) 966-4087 | Family Practice By The Lake Llc 1875 N Lakewood Dr Ste 205 Coeur D Alene ID 83814-4928 Ph: (208) 966-4087 |
| NPI Number | 1295283810 |
|---|---|
| Provider Enumeration Date | 09/12/2016 |
| Last Update Date | 03/25/2024 |
| Medicare PECOS PAC ID | 7113205931 |
|---|---|
| Medicare Enrollment ID | O20161031000460 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1295283810 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| 363L00000X | Nurse Practitioner | (* (Not Available)) | Secondary |
| Provider Name | Jacqueline L Wagner |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1447598362 PECOS PAC ID: 7315187093 Enrollment ID: I20140407000617 |
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