Healthcare Provider Details

I. General information

NPI: 1396970612
Provider Name (Legal Business Name): COLEEN D HULBERT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: COLEEN DENISE HASSELL M.D.

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 E STATE ST STE 1100
EAGLE ID
83616-6232
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-473-3500
  • Fax:
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTRN13814
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM11814
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: