Basic Information
Provider Information | |||||||||
NPI: | 1558680587 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SNOW | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | DOXEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3525 E LOUISE DR STE 195 | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | ID | ||||||||
PostalCode: | 836426303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088468335 | ||||||||
FaxNumber: | 2084720526 | ||||||||
Practice Location | |||||||||
Address1: | 4424 E FLAMINGO AVE STE 340 | ||||||||
Address2: |   | ||||||||
City: | NAMPA | ||||||||
State: | ID | ||||||||
PostalCode: | 836879306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088468335 | ||||||||
FaxNumber: | 2088468336 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2010 | ||||||||
LastUpdateDate: | 05/01/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 012787 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 208D00000X | 0102202953 | VA | N |   | Allopathic & Osteopathic Physicians | General Practice |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207RN0300X | O-1209 | ID | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | FS6845171 | 01 | ID | DEA | OTHER |