Healthcare Provider Details

I. General information

NPI: 1487958161
Provider Name (Legal Business Name): SUSAN J. HEGSTAD, M.D., PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 01/10/2011
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:
Mailing address:
  • Phone: 208-344-1281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SUSAN J HEGSTAD
Title or Position: OWNER
Credential: M.D.
Phone: 208-344-1281