=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619934213
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDALL D. JENKINS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2006
-----------------------------------------------------
Last Update Date | 01/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E IDAHO ST SUITE 304
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-381-7336
-----------------------------------------------------
Fax | 208-381-7029
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 E BANNOCK ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83712-6241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-706-8449
-----------------------------------------------------
Fax | 208-381-7029
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0210X
-----------------------------------------------------
Taxonomy Name | Pediatric Nephrology Physician
-----------------------------------------------------
License Number | 12771
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080P0210X
-----------------------------------------------------
Taxonomy Name | Pediatric Nephrology Physician
-----------------------------------------------------
License Number | M-6953
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------