Healthcare Provider Details

I. General information

NPI: 1427138734
Provider Name (Legal Business Name): ASTHMA & ALLERGY OF IDAHO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 LOCUST ST N STE 600
TWIN FALLS ID
83301-4164
US

IV. Provider business mailing address

1502 LOCUST ST N STE 600
TWIN FALLS ID
83301-4164
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-6091
  • Fax: 208-734-4654
Mailing address:
  • Phone: 208-734-6091
  • Fax: 208-734-4654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREW WICKERN
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 208-734-6091