Healthcare Provider Details

I. General information

NPI: 1225813595
Provider Name (Legal Business Name): TRAVIS BLASER FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2023
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 N EAGLE RD
BOISE ID
83713-4722
US

IV. Provider business mailing address

8454 N PIERCE PARK RD
BOISE ID
83714-2505
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-3110
  • Fax:
Mailing address:
  • Phone: 608-780-2742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number77386
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: