Healthcare Provider Details

I. General information

NPI: 1619085271
Provider Name (Legal Business Name): MR. RANDALL S ZAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W STATE ST
BOISE ID
83702-6127
US

IV. Provider business mailing address

111 W STATE ST
BOISE ID
83702-6127
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-0895
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA-112
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: