Provider Demographics
NPI:1629685235
Name:ROUBIDOUX, MARK MITCHELL II (NP-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:MITCHELL
Last Name:ROUBIDOUX
Suffix:II
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E NEIDER AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-6007
Mailing Address - Country:US
Mailing Address - Phone:208-930-4944
Mailing Address - Fax:877-376-4040
Practice Address - Street 1:336 WARNER DR STE 4A
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4441
Practice Address - Country:US
Practice Address - Phone:208-305-3537
Practice Address - Fax:877-376-4040
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID39235363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty