Healthcare Provider Details

I. General information

NPI: 1194773598
Provider Name (Legal Business Name): KIMBERLY R TANABE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 E STATE ST SUITE 2120
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: 208-473-3275
  • Fax: 208-473-3276
Mailing address:
  • Phone: 208-706-8000
  • Fax: 208-706-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM5831
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: