Healthcare Provider Details

I. General information

NPI: 1487693032
Provider Name (Legal Business Name): BOISE OBSTETRIC & GYNECOLOGIC ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5966 CURTISIAN AVE
BOISE ID
83704
US

IV. Provider business mailing address

5966 CURTISIAN AVE
BOISE ID
83704
US

V. Phone/Fax

Practice location:
  • Phone: 208-375-8100
  • Fax: 208-373-2643
Mailing address:
  • Phone: 208-375-8100
  • Fax: 208-373-2643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHERYL R GLEASON
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 208-375-8100