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General NPI Number Information
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NPI Number | 1164459541
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Entity Type | Individual
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Provider Name | JON PARKER WAGNILD MD
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Gender | Male
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Dates
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Enumeration Date | 06/28/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 5610 GAGE ST SUITE A
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City | BOISE
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State | ID
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Zip | 83706-1349
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Country | US
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Telephone | 208-367-3370
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Fax |
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Provider Business Mailing Address
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Address Line | 984 W BOGUS VIEW CT
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City | EAGLE
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State | ID
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Zip | 83616-5878
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | M4213
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License Number State | ID
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