Healthcare Provider Details

I. General information

NPI: 1124956669
Provider Name (Legal Business Name): MUTABAZI NSHIMIYIMANA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

963 S ORCHARD ST
BOISE ID
83705-1939
US

IV. Provider business mailing address

963 S ORCHARD ST
BOISE ID
83705-1939
US

V. Phone/Fax

Practice location:
  • Phone: 208-513-5342
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: