Healthcare Provider Details

I. General information

NPI: 1487602298
Provider Name (Legal Business Name): BOISE ANESTHESIA, P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1352
US

IV. Provider business mailing address

PO BOX 3750
SALT LAKE CITY UT
84110-3750
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6416
  • Fax:
Mailing address:
  • Phone: 800-945-9877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberN/A
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW BRYAN FOWLER
Title or Position: PRESIDENT
Credential: MD
Phone: 208-367-6416