Basic Information
Provider Information
NPI: 1740239599
EntityType: 2
ReplacementNPI:  
OrganizationName: BOISE ANESTHESIA, PA
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Mailing Information
Address1: PO BOX 3750
Address2:  
City: SALT LAKE CITY
State: UT
PostalCode: 841103750
CountryCode: US
TelephoneNumber: 8009459877
FaxNumber:  
Practice Location
Address1: 1055 N CURTIS RD
Address2:  
City: BOISE
State: ID
PostalCode: 837061352
CountryCode: US
TelephoneNumber: 2083676416
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/09/2006
LastUpdateDate: 07/18/2018
NPIDeactivationReasonCode:  
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ProviderGenderCode:  
AuthorizedOfficialLastName: FOWLER
AuthorizedOfficialFirstName: MATTHEW
AuthorizedOfficialMiddleName: BRYAN
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 2083676416
IsSoleProprietor:  
IsOrganizationSubpart: N
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AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207L00000XN/A Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansAnesthesiology 

ID Information
IDTypeStateIssuerDescription
M002644205ID MEDICAID


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