Healthcare Provider Details

I. General information

NPI: 1801765524
Provider Name (Legal Business Name): GABRIEL FAJARDO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2025
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST
BOISE ID
83702-4599
US

IV. Provider business mailing address

1622 W TETON AVE
NAMPA ID
83686-4820
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1092
  • Fax:
Mailing address:
  • Phone: 208-422-1092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0100X
TaxonomyGastroenterology Registered Nurse
License Number60578
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: