Healthcare Provider Details

I. General information

NPI: 1528501392
Provider Name (Legal Business Name): NICHOLAS ANDERSEN RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9730 W MOSSYWOOD DR
BOISE ID
83709-5392
US

IV. Provider business mailing address

9730 W MOSSYWOOD DR
BOISE ID
83709-5392
US

V. Phone/Fax

Practice location:
  • Phone: 208-954-7433
  • Fax:
Mailing address:
  • Phone: 208-954-7433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberLRT-1601
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: