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General NPI Number Information
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NPI Number | 1134905243
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Entity Type | Organization
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Legal Business Name | BOISE STATE UNIVERSITY
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Dates
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Enumeration Date | 09/05/2023
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Last Update Date | 08/29/2024
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Provider Practice Location Address
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Address Line | 2100 UNIVERSITY DR STE 107
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City | BOISE
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State | ID
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Zip | 83725-0001
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Country | US
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Telephone | 208-426-1523
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Fax | 208-426-2302
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Provider Business Mailing Address
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Address Line | 1910 UNIVERSITY DR # MS 1855
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City | BOISE
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State | ID
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Zip | 83725
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Country | US
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Telephone | 208-426-1523
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Fax | 208-426-2302
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Authorized Official
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Title or Position | CLINICAL PROGRAM DIRECTOR
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Name | DR. STEPHANIE HUDON
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Credential | PHD
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Telephone | 208-995-3765
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2083P0901X
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Taxonomy Name | Public Health & General Preventive Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State |
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