Healthcare Provider Details

I. General information

NPI: 1437143161
Provider Name (Legal Business Name): KEITH R SWAINSTON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 E FAIRVIEW AVE
MERIDIAN ID
83642-1813
US

IV. Provider business mailing address

PO BOX 314
MERIDIAN ID
83680-0314
US

V. Phone/Fax

Practice location:
  • Phone: 208-895-6729
  • Fax: 208-855-5921
Mailing address:
  • Phone: 208-895-6729
  • Fax: 208-855-5921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21058.315
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP-823A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: