Healthcare Provider Details

I. General information

NPI: 1033154828
Provider Name (Legal Business Name): NOREEN A. WOMACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 09/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 W STATE ST SUITE 100
EAGLE ID
83616-7057
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-1035
  • Fax: 208-939-8970
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM8127
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: