Healthcare Provider Details

I. General information

NPI: 1598085490
Provider Name (Legal Business Name): PRANABH SHRESTHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S MAIN ST
MOSCOW ID
83843
US

IV. Provider business mailing address

700 S MAIN ST
MOSCOW ID
83843-3046
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-4511
  • Fax:
Mailing address:
  • Phone: 208-882-4511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberM-14643
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberM-14643
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD61325352
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberM-14643
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: