Healthcare Provider Details

I. General information

NPI: 1962367029
Provider Name (Legal Business Name): STACEY LYNN ADAN CST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2025
Last Update Date: 02/22/2026
Certification Date: 02/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8800 W EMERALD ST
BOISE ID
83704-8205
US

IV. Provider business mailing address

16 S BINGHAM ST
NAMPA ID
83651-7650
US

V. Phone/Fax

Practice location:
  • Phone: 208-373-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: