Healthcare Provider Details

I. General information

NPI: 1841941572
Provider Name (Legal Business Name): AUSTIN COLEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2022
Last Update Date: 07/22/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT STREET BVAMC WELLNESS CENTER B.116
BOISE ID
83702
US

IV. Provider business mailing address

500 W FORT STREET BVAMC WELLNESS CENTER B.116
BOISE ID
83702
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1165
  • Fax:
Mailing address:
  • Phone: 208-422-1165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMRO-2352
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: