Healthcare Provider Details

I. General information

NPI: 1538192810
Provider Name (Legal Business Name): ROCKY WADE ELSASSER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

943 N LINDER RD SUITE 104
KUNA ID
63634-3395
US

IV. Provider business mailing address

2176 E FRANKLIN RD SUITE 100
MERIDIAN ID
83642-9024
US

V. Phone/Fax

Practice location:
  • Phone: 208-922-1719
  • Fax: 208-922-1721
Mailing address:
  • Phone: 208-288-1155
  • Fax: 208-288-0424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number49332238-2401
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2180
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: