Basic Information
| Provider Information | |||||||||
| NPI: | 1144212689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STUTZMAN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | KAHLER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KAHLER | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 777 N RAYMOND ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837049251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083676042 | ||||||||
| FaxNumber: | 2083227018 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 N RAYMOND ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837049251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083676042 | ||||||||
| FaxNumber: | 2083227018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 06/09/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD0031115 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD19694 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | M9972 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 805823200 | 05 | ID | MEDICAID | 8159519 | 05 | WA | MEDICAID |