Basic Information
| Provider Information | |||||||||
| NPI: | 1164439725 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HODGMAN | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 E GOLDSTONE DR | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083020200 | ||||||||
| FaxNumber: | 2083020255 | ||||||||
| Practice Location | |||||||||
| Address1: | 4424 E FLAMINGO AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083020200 | ||||||||
| FaxNumber: | 2083020255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 38352 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | M-14705 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | CA3899 | 01 | RR MEDICARE GROUP | OTHER | POO731202 | 01 | RR MEDICARE INDIV | OTHER | 71960 | 01 | MEDICARE GROUP | OTHER |