Healthcare Provider Details

I. General information

NPI: 1649242025
Provider Name (Legal Business Name): STACY DIANE OSTLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STACY DIANE SHOEMAKER MD

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 E PLAZA DR STE 103
EAGLE ID
83616-6549
US

IV. Provider business mailing address

PO BOX 434
EAGLE ID
83616-0434
US

V. Phone/Fax

Practice location:
  • Phone: 208-229-7075
  • Fax:
Mailing address:
  • Phone: 208-229-7075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA68685
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberM-9953
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD00049170
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: