Healthcare Provider Details

I. General information

NPI: 1821727140
Provider Name (Legal Business Name): JOSEBA BIDABURU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2022
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: 208-895-8670
  • Fax: 208-955-0494
Mailing address:
  • Phone: 208-985-1423
  • Fax: 208-955-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2742
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: