Healthcare Provider Details

I. General information

NPI: 1801393616
Provider Name (Legal Business Name): EAST TO WEST FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051A E SUMMERSWEET DR
BOISE ID
83716
US

IV. Provider business mailing address

2051A E SUMMERSWEET DR
BOISE ID
83716-6695
US

V. Phone/Fax

Practice location:
  • Phone: 208-908-1041
  • Fax:
Mailing address:
  • Phone: 208-395-1090
  • Fax: 208-395-1093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number37185
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP1522A
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP1522A
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberNP1522A
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberNP1522A
License Number StateID
# 6
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberNP1522A
License Number StateID
# 7
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP1522A
License Number StateID

VIII. Authorized Official

Name: KATHLEEN LEWIS
Title or Position: MANAGER
Credential:
Phone: 208-955-8215