Healthcare Provider Details

I. General information

NPI: 1902179914
Provider Name (Legal Business Name): GARY GREGERSON MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 12TH AVE ROAD SUITE A
NAMPA ID
83686-6182
US

IV. Provider business mailing address

1611 12TH AVE ROAD SUITE A
NAMPA ID
83686-6182
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 N GREGERSON
Title or Position: SOLE OWNER
Credential: MD
Phone: 208-468-9400