Healthcare Provider Details

I. General information

NPI: 1023146057
Provider Name (Legal Business Name): RICHARD A WATHNE, MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 E CENTER ST
POCATELLO ID
83201-2600
US

IV. Provider business mailing address

2240 E CENTER ST
POCATELLO ID
83201-2600
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2100
  • Fax: 208-233-3146
Mailing address:
  • Phone: 208-233-2100
  • Fax: 208-233-3146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM6663
License Number StateID

VIII. Authorized Official

Name: DR. RICHARD A WATHNE
Title or Position: PRESIDENT
Credential: MD
Phone: 208-233-2100