Healthcare Provider Details

I. General information

NPI: 1871618892
Provider Name (Legal Business Name): LIFESTAGES OB-GYN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3908 E FLAMINGO AVE
NAMPA ID
83687-3102
US

IV. Provider business mailing address

3908 E FLAMINGO AVE
NAMPA ID
83687-3102
US

V. Phone/Fax

Practice location:
  • Phone: 208-442-8035
  • Fax: 208-442-8038
Mailing address:
  • Phone: 208-442-8035
  • Fax: 208-442-8038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberM8105
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberM8055
License Number StateID

VIII. Authorized Official

Name: DUSTAN HUGHES
Title or Position: OWNER
Credential: M.D.
Phone: 208-442-8038