Healthcare Provider Details

I. General information

NPI: 1255762506
Provider Name (Legal Business Name): GARY GREGERSON, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 12TH AVE RD SUITE A
NAMPA ID
83686-7715
US

IV. Provider business mailing address

1611 12TH AVE RD SUITE A
NAMPA ID
83686-7715
US

V. Phone/Fax

Practice location:
  • Phone: 208-468-9400
  • Fax: 208-468-9447
Mailing address:
  • Phone: 208-468-9400
  • Fax: 208-468-9447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberM-6312
License Number StateID

VIII. Authorized Official

Name: GARY NED GREGERSON
Title or Position: PRESIDENT
Credential:
Phone: 208-468-9400