Healthcare Provider Details

I. General information

NPI: 1386921294
Provider Name (Legal Business Name): COMPREHENSIVE DERMATOLOGY OF IDAHO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2011
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16111 N BRINSON ST STE 100
NAMPA ID
83687-5509
US

IV. Provider business mailing address

16111 N BRINSON ST STE 100
NAMPA ID
83687-5509
US

V. Phone/Fax

Practice location:
  • Phone: 208-467-7546
  • Fax: 208-467-7500
Mailing address:
  • Phone: 208-467-7546
  • Fax: 208-467-7500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM8483
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA280
License Number StateID

VIII. Authorized Official

Name: DR. RYAN SCOTT OWSLEY
Title or Position: OWNER
Credential: M.D.
Phone: 208-467-7546