Healthcare Provider Details

I. General information

NPI: 1225324361
Provider Name (Legal Business Name): CHRISTOPHER RYAN BOONE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 W CHINDEN BLVD
GARDEN CITY ID
83714-1463
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-809-2865
  • Fax: 208-809-2866
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.138833
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0058728
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-16455
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-41559
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: