=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649539164
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATE BOYLE RN, MSN, FNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2012
-----------------------------------------------------
Last Update Date | 06/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 CHANNING WAY
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-7533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-227-2001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1710 MARSALA CT
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83401-6283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-552-0478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | N-37724
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | NP-1159A
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------