Basic Information
| Provider Information | |||||||||
| NPI: | 1245267541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRONNER | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087068526 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4840 CLOVERDALE ROAD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087068000 | ||||||||
| FaxNumber: | 2087068001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 01/25/2016 | ||||||||
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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 | 207R00000X | M-12730 | ID | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.