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General NPI Number Information
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NPI Number | 1972275501
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Entity Type | Individual
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Provider Name | ROBERTA J. BOSTIAN AGACNP
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Gender | Female
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Dates
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Enumeration Date | 10/01/2021
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Last Update Date | 09/12/2023
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Provider Practice Location Address
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Address Line | 765 S UTAH AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83402-5093
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Country | US
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Telephone | 208-525-2600
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Fax |
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Provider Business Mailing Address
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Address Line | 2325 CORONADO ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7407
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Country | US
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Telephone | 208-557-2700
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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 | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 68854
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 12751401-4405
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License Number State | UT
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