Healthcare Provider Details

I. General information

NPI: 1417054693
Provider Name (Legal Business Name): EAGLE FAMILY MEDICINE P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COTTONWOOD CT SUITE 100
EAGLE ID
83616-6576
US

IV. Provider business mailing address

100 COTTONWOOD CT SUITE 100
EAGLE ID
83616-6576
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-3197
  • Fax: 208-939-3263
Mailing address:
  • Phone: 208-939-3197
  • Fax: 208-939-3263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-7050
License Number StateID

VIII. Authorized Official

Name: DR. SHAWN CHRISTIAN NOWIERSKI
Title or Position: OWNER
Credential: MD
Phone: 208-939-3197