Healthcare Provider Details

I. General information

NPI: 1891733663
Provider Name (Legal Business Name): DARRYL D BARNES PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 S BROADWAY AVE # 101
BOISE ID
83706-4201
US

IV. Provider business mailing address

1907 S BROADWAY AVE # 101
BOISE ID
83706-4201
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-1222
  • Fax: 208-345-1261
Mailing address:
  • Phone: 208-345-1222
  • Fax: 208-345-1261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA315
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: