Healthcare Provider Details

I. General information

NPI: 1174156418
Provider Name (Legal Business Name): LEA JO PIPER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2020
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 E MAGIC VIEW DR
MERIDIAN ID
83642-6245
US

IV. Provider business mailing address

3483 E EISENHOWER DR
MERIDIAN ID
83642-6019
US

V. Phone/Fax

Practice location:
  • Phone: 208-639-4900
  • Fax:
Mailing address:
  • Phone: 208-539-3340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number19-165
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: