Healthcare Provider Details

I. General information

NPI: 1396436739
Provider Name (Legal Business Name): NOAH M NUNEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 PERIMERTER DR
MOSCOW ID
83844-0001
US

IV. Provider business mailing address

1139 WEST RD
LA HABRA HEIGHTS CA
90631-8632
US

V. Phone/Fax

Practice location:
  • Phone: 208-855-6111
  • Fax:
Mailing address:
  • Phone: 626-222-9137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: