Healthcare Provider Details

I. General information

NPI: 1528882073
Provider Name (Legal Business Name): RAQUEL DIANA DEMEYER ATS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 S TALLOWTREE WAY
BOISE ID
83716-6963
US

IV. Provider business mailing address

5810 S TALLOWTREE WAY
BOISE ID
83716-6963
US

V. Phone/Fax

Practice location:
  • Phone: 208-794-4759
  • Fax:
Mailing address:
  • Phone: 208-794-4759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number8571363
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: