Basic Information
| Provider Information | |||||||||
| NPI: | 1376298539 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | MADELAINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1611 E BOISE AVE | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837065401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082845184 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 E JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083221680 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2022 | ||||||||
| LastUpdateDate: | 03/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 60087 | ID | N | Nursing Service Providers | Registered Nurse | 363LA2100X | 60087 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.