MARCUS ISMEDHI MUTIDJO (NPI# 1063825446) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1063825446 |
| Entity Type | Individual |
| Full Name | MARCUS ISMEDHI MUTIDJO |
| Credential | APN |
| Practice Address |
1701 W Garden St Peoria IL 61605 |
| Mailing Address |
2214 N University St Peoria IL 61604-3221 |
| Practice Telephone | 3096807600 |
| Practice Fax Number | 3096807686 |
| Mailing Telephone | 3096807669 |
| Mailing Fax Number | 3096818443 |
| Enumeration Date | 2014-06-03 |
| Last Update Date | 2019-01-14 |
| Gender Code | M |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 363LF0000X |
Nurse Practitioner Specialization: Family |
209016806 | IL | Physician Assistants & Advanced Practice Nursing Providers |
| Address | Telephone Number | Fax Number |
|---|---|---|
| 601 Sunland Park Dr, Bldg One, El Paso, TX 799125131 | 9155331622 | |
| 819 Bloomington Rd, Champaign, IL 618202101 | 2174035498 |
| Street Address |
1701 W GARDEN ST |
| City | PEORIA |
| State | IL |
| Zip Code | 61605 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1871599522 | David Carl Gregory | Family Medicine | 1701 W Garden St, Peoria, IL 61605-3531 | 2005-06-27 |
| 1144793639 | John Alexander-blair Ramirez | Social Worker | 1701 W Garden St, Peoria, IL 61605-3531 | 2019-01-07 |
| 1376925586 | Shannon Diann Pyle | Nurse Practitioner | 1701 W Garden St, Peoria, IL 61605-3531 | 2015-06-24 |
| 1487054425 | Kathryn M Endress | Nurse Practitioner | 1701 W Garden St, Peoria, IL 61605-3531 | 2014-08-27 |
| 1053662783 | Edward E Etherton | Nurse Practitioner | 1701 W Garden St, Peoria, IL 61605-3531 | 2012-09-20 |
| 1710210711 | Amy M. Light | Counselor | 1701 W Garden St, Peoria, IL 61605-3531 | 2009-09-09 |
| 1902951957 | Tina R Saddler | Nurse Practitioner | 1701 W Garden St, Peoria, IL 61605-3531 | 2007-01-23 |
| 1467546218 | Gregg D Stoner | Family Medicine | 1701 W Garden St, Peoria, IL 61605-3531 | 2006-10-03 |
| 1790889392 | Sandra K. Leman | Physician Assistant | 1701 W Garden St, Peoria, IL 61605-3531 | 2006-09-12 |
| 1629092226 | Thembi A Conner-garcia | Internal Medicine | 1701 W Garden St, Peoria, IL 61605 | 2006-07-27 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1386131878 | Nicholas Anthony Helling | Physical Therapist | 518 W Romero B Garret Ave, Poeria, IL 61605 | 2018-04-19 |
| 1891241022 | Peoria Slf Lp | Assisted Living Facility | 518 West Romeo B. Garrett Avenue, Peoria, IL 61605 | 2016-08-28 |
| 1932479664 | Michelle L Whitelow | Nurse Practitioner | 711 W John Gwynn Jr. Avenue, Peoria, IL 61605 | 2012-01-11 |
| 1982852877 | Jason M Anane-sefah | Orthopaedic Surgery | 303 North Kumpf Boulevard, Peoria, IL 61605 | 2008-09-04 |
| 1902098908 | Calvary Elderly Home Help Program | Home Health | 1709 W Lincoln Ave, Peoria, IL 61605 | 2007-08-14 |
| 1023104437 | Thomas Anderson | Optometrist | 710 W Third Avenue, Peoria, IL 61605 | 2006-10-04 |
| 1841382298 | Devashish Agarwal | Family Medicine | 1701 W. Garden Street, Peoria, IL 61605 | 2006-09-29 |
| 1497763197 | Larry T Rolle | Pharmacist | 411 Martin Luther King Dr., Peoria, IL 61605 | 2006-08-04 |
| 1568404762 | Joseph P Kelly Iv | Physical Therapist | 303 N. Kumpf Blvd, Peoria, IL 61605 | 2006-06-12 |
| 1003861634 | Patrick William Elwood | Neurological Surgery | 719 N William Kumpf Blvd, Suite 100, Peoria, IL 61605 | 2006-05-23 |
| Find all providers in zip 61605 | ||||
| Taxonomy Code | 363LF0000X |
| Grouping | Physician Assistants & Advanced Practice Nursing Providers |
| Classification | Nurse Practitioner |
| Specialization | Family |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1881295541 | Britney Julia Durst | Nurse Practitioner | 5905 N Prospect Rd, Peoria, IL 61614-4311 | 2020-11-07 |
| 1598362980 | Courtney Klein | Nurse Practitioner | 1306 N. Berkley Ave, Peoria, IL 61603 | 2020-10-08 |
| 1699390039 | Steven Joel Schlink | Nurse Practitioner | 12920 W Roy Rogers Rd, Peoria, AZ 85383-5334 | 2020-06-11 |
| 1457986929 | Chanelle Christine Maclin | Nurse Practitioner | 504 E Kansas St, Peoria, IL 61603-2554 | 2020-03-05 |
| 1225677495 | Michelle Chacon | Nurse Practitioner | 23201 N 87th Dr, Peoria, AZ 85383-1860 | 2020-01-05 |
| 1689218042 | Patricia Nwakaego Ayemoba | Nurse Practitioner | 16018 N 74th Dr, Peoria, AZ 85382-1810 | 2019-10-29 |
| 1144877267 | Eunice Wright | Nurse Practitioner | 26826 N 85th Dr, Peoria, AZ 85383-3624 | 2019-08-22 |
| 1861057507 | Shawnee Renee Fudurich | Nurse Practitioner | 10230 W Happy Valley Pkwy Ste 100, Peoria, AZ 85383-4255 | 2019-05-08 |
| 1265096895 | Razel Espiritu Hernandez | Nurse Practitioner | 25435 N 115th Ave, Peoria, AZ 85383-9789 | 2019-04-29 |
| 1619435310 | Jennifer Gayle Ries-clark | Nurse Practitioner | 8009 W Salter Dr, Peoria, AZ 85382-4440 | 2019-03-12 |
| Find all providers in PEORIA | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.