Healthcare Provider Details

I. General information

NPI: 1245645589
Provider Name (Legal Business Name): JASON NEALY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 N EAGLE RD
BOISE ID
83713-4722
US

IV. Provider business mailing address

15320 OLD REDMOND RD
REDMOND WA
98052-6837
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-3110
  • Fax:
Mailing address:
  • Phone: 970-581-8761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number60961766
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number60961766
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: