Healthcare Provider Details

I. General information

NPI: 1902535552
Provider Name (Legal Business Name): SYDNEY JADE POORBAUGH DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 N EISENHOWER ST
MOSCOW ID
83843-9588
US

IV. Provider business mailing address

2602 BLUE MOUNTAIN CT
CLARKSTON WA
99403-1693
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-6560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPT-7109
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: