Healthcare Provider Details

I. General information

NPI: 1619858792
Provider Name (Legal Business Name): CONNOR MCNAIRY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 W BROADWAY ST
IDAHO FALLS ID
83402-2902
US

IV. Provider business mailing address

2275 W BROADWAY ST
IDAHO FALLS ID
83402-2902
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-7400
  • Fax:
Mailing address:
  • Phone: 208-524-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2871879
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: