Healthcare Provider Details

I. General information

NPI: 1356306740
Provider Name (Legal Business Name): KIMBERLY D FERGUISON MD-PEDIATRICS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY D GRANWEHR

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3280 E LANARK DR
MERIDIAN ID
83642-5982
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-4400
  • Fax: 208-377-4416
Mailing address:
  • Phone: 208-955-6500
  • Fax: 208-955-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM9507
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: