Healthcare Provider Details

I. General information

NPI: 1497797302
Provider Name (Legal Business Name): ANN C AGNEW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 E GENTRY WAY STE 210
MERIDIAN ID
83642-3013
US

IV. Provider business mailing address

1070 E OPUS ST
BOISE ID
83716-5274
US

V. Phone/Fax

Practice location:
  • Phone: 208-947-5390
  • Fax: 208-947-3465
Mailing address:
  • Phone: 208-344-4824
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberM9138
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM9138
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: