Healthcare Provider Details

I. General information

NPI: 1609584119
Provider Name (Legal Business Name): MARY AMANDA BASHISTA RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST
BOISE ID
83702-4598
US

IV. Provider business mailing address

500 W FORT ST
BOISE ID
83702-4598
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1420
  • Fax: 208-422-1293
Mailing address:
  • Phone: 208-422-1420
  • Fax: 208-422-1293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberLRT-914
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: