Healthcare Provider Details

I. General information

NPI: 1477226272
Provider Name (Legal Business Name): LISA WOOD RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 07/28/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST
BOISE ID
83702-4501
US

IV. Provider business mailing address

9573 W SILVERSPRING ST
BOISE ID
83709-5762
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1000
  • Fax:
Mailing address:
  • Phone: 208-585-7456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberLRT-1234
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: