Healthcare Provider Details

I. General information

NPI: 1588408702
Provider Name (Legal Business Name): JAKE KOTR MONAGHAN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 N COLE RD
BOISE ID
83704-8537
US

IV. Provider business mailing address

10482 W CARLTON BAY DR
GARDEN CITY ID
83714-5143
US

V. Phone/Fax

Practice location:
  • Phone: 208-809-2880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number73209
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: