Basic Information
| Provider Information | |||||||||
| NPI: | 1821042334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANGLETON | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANGLETON | ||||||||
| OtherFirstName: | PETER | ||||||||
| OtherMiddleName: | JOHN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2963 E COPPER POINT DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083221730 | ||||||||
| FaxNumber: | 2083221731 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N CURTIS RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083221730 | ||||||||
| FaxNumber: | 2083221731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 09/25/2017 | ||||||||
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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 | 207P00000X | MD183357 | OR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | M5573 | ID | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 004026000 | 05 | ID | MEDICAID |