Healthcare Provider Details

I. General information

NPI: 1700827508
Provider Name (Legal Business Name): PENNY MICHELLE FAIRES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N RAYMOND ST
BOISE ID
83704-9251
US

IV. Provider business mailing address

777 N RAYMOND ST
BOISE ID
83704-9251
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6030
  • Fax: 208-367-6123
Mailing address:
  • Phone: 208-367-6030
  • Fax: 208-367-6123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMR0824
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: