Healthcare Provider Details

I. General information

NPI: 1053609073
Provider Name (Legal Business Name): KAITLIN C NEARY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 04/22/2024
Certification Date: 02/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 W EMERALD ST STE 168
BOISE ID
83704-8296
US

IV. Provider business mailing address

8950 W EMERALD ST STE 168
BOISE ID
83704-8296
US

V. Phone/Fax

Practice location:
  • Phone: 208-321-1209
  • Fax: 208-321-1211
Mailing address:
  • Phone: 208-321-1209
  • Fax: 208-321-1211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number16821
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number6556
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number16821
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: