Basic Information
| Provider Information | |||||||||
| NPI: | 1518924026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FALL | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 587 | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833030587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088147400 | ||||||||
| FaxNumber: | 2088147491 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 POLE LINE RD W | ||||||||
| Address2: | SUITE 3880 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088148500 | ||||||||
| FaxNumber: | 2088148596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 04/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | M6080 | ID | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207Q00000X | M6080 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000209800 | 05 | ID | MEDICAID |