Healthcare Provider Details

I. General information

NPI: 1306870761
Provider Name (Legal Business Name): SUMIKO JOAN HEGSTAD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN J. HEGSTAD MD

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 N 2ND ST STE 102
BOISE ID
83702-6129
US

IV. Provider business mailing address

222 N 2ND ST STE 102
BOISE ID
83702-6129
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-1281
  • Fax: 208-344-1696
Mailing address:
  • Phone: 208-344-1281
  • Fax: 208-344-1696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberM6778
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: