Healthcare Provider Details

I. General information

NPI: 1639088859
Provider Name (Legal Business Name): SHUKURU GASANA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9428 W FAIRVIEW AVE
BOISE ID
83704-8101
US

IV. Provider business mailing address

3735 N GLENWOOD ST
BOISE ID
83704-4478
US

V. Phone/Fax

Practice location:
  • Phone: 986-301-0460
  • Fax:
Mailing address:
  • Phone: 208-890-8356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: