Healthcare Provider Details

I. General information

NPI: 1891256004
Provider Name (Legal Business Name): RYAN THOMPSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

PO BOX 7411114
CHICAGO IL
60674-1114
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6416
  • Fax:
Mailing address:
  • Phone: 208-367-5170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberO-1837
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMRO-1806
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: