Healthcare Provider Details

I. General information

NPI: 1548170129
Provider Name (Legal Business Name): DOUGLAS T BOSSARD RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 606
ASHTON ID
83420-0606
US

IV. Provider business mailing address

PO BOX 606
ASHTON ID
83420-0606
US

V. Phone/Fax

Practice location:
  • Phone: 208-652-7461
  • Fax: 208-652-7595
Mailing address:
  • Phone: 208-652-7461
  • Fax: 208-652-7595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number40148
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: