Healthcare Provider Details

I. General information

NPI: 1740346188
Provider Name (Legal Business Name): VERA PAULINE MANSFIELD CST, SA-C, CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VERA PAULINE THOMAS

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 E RIVERSIDE DR APT H303
EAGLE ID
83616-7552
US

IV. Provider business mailing address

2411 E RIVERSIDE DR APT H303
EAGLE ID
83616-7552
US

V. Phone/Fax

Practice location:
  • Phone: 208-724-2223
  • Fax:
Mailing address:
  • Phone: 208-724-2223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number109984
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number109984
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: