MEDICARE: SANTIBANEZ PAC IDAHO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	363A00000X	Physician Assistant
2	363L00000X	Nurse Practitioner
3	207RG0300X	Geriatric Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1346015948
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANTIBANEZ PAC IDAHO

Provider Business Mailing Address
First Line	:	10775 DOUBLE R BLVD
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89521-8956
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	840 E ELVA ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-2801
Country	:	US
Telephone Number	:	208-523-4795
Fax Number	:

Authorized Official
Title or Position	:	VP OF OPERATIONS
Name	:	JULIE ROSER
Credential	:
Telephone Number	:	775-222-0045

Provider Enumeration Date	:	11/24/2023
Last Update Date	:	01/14/2025

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Directions to “SANTIBANEZ PAC IDAHO ” Practice Location

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