MEDICARE: GUNNAR HARRISON MAUGHAN MSPO, CPO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1164121562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GUNNAR HARRISON MAUGHAN MSPO, CPO

Provider Business Mailing Address
First Line	:	130 W RIVER HEIGHTS DR
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5120
Country	:	US
Telephone Number	:	208-866-5177
Fax Number	:

Provider Business Practice Location Address
First Line	:	9632 W EMERALD ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-9762
Country	:	US
Telephone Number	:	208-866-5177
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2023
Last Update Date	:	02/24/2023

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