Healthcare Provider Details

I. General information

NPI: 1659540292
Provider Name (Legal Business Name): POCATELLO CARDIOLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY BLDG A STE. 101
POCATELLO ID
83201-2753
US

IV. Provider business mailing address

PO BOX O
POCATELLO ID
83205-0049
US

V. Phone/Fax

Practice location:
  • Phone: 208-234-2001
  • Fax: 208-232-2195
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE P CONOLEY
Title or Position: CLINIC ADMINSTRATOR
Credential:
Phone: 208-234-2001