Healthcare Provider Details

I. General information

NPI: 1336951649
Provider Name (Legal Business Name): MATTHEW HARGIS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 S BRIDGEWAY PL
EAGLE ID
83616-6099
US

IV. Provider business mailing address

PO BOX 4302
BOISE ID
83711-4302
US

V. Phone/Fax

Practice location:
  • Phone: 208-246-0123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4971843
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: