Provider Demographics
NPI:1881301075
Name:CRISWELL, JON PATXI (FNP-C)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:PATXI
Last Name:CRISWELL
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3271 N MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4425
Mailing Address - Country:US
Mailing Address - Phone:208-996-1700
Mailing Address - Fax:
Practice Address - Street 1:3271 N MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4425
Practice Address - Country:US
Practice Address - Phone:208-996-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-28
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID61604363LP0808X, 363LF0000X
ID899421363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health