Basic Information
| Provider Information | |||||||||
| NPI: | 1295900744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEYES | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N 1ST ST | ||||||||
| Address2: | STE 280 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837026100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083456545 | ||||||||
| FaxNumber: | 2083451213 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 N 1ST ST | ||||||||
| Address2: | STE 280 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837026100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083456545 | ||||||||
| FaxNumber: | 2083451213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2008 | ||||||||
| LastUpdateDate: | 04/25/2008 | ||||||||
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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 | 246X00000X | 89506 | ID | Y | Technologists, Technicians & Other Technical Service Providers | Spec/Tech, Cardiovascular |
No ID Information.