Basic Information
| Provider Information | |||||||||
| NPI: | 1972275501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSTIAN | ||||||||
| FirstName: | ROBERTA | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | AGACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2325 CORONADO ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085572700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 765 S UTAH AVE | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834025093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2021 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 68854 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.