Healthcare Provider Details

I. General information

NPI: 1629036264
Provider Name (Legal Business Name): LAIRA LUE THOMAS F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W CAMAS AVE
FAIRFIELD ID
83327
US

IV. Provider business mailing address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

V. Phone/Fax

Practice location:
  • Phone: 208-764-2611
  • Fax: 208-764-2646
Mailing address:
  • Phone: 208-734-3312
  • Fax: 208-734-3313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-327A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: