Provider Demographics
NPI:1033154828
Name:WOMACK, NOREEN A (MD)
Entity Type:Individual
Prefix:
First Name:NOREEN
Middle Name:A
Last Name:WOMACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:450 W STATE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-7057
Practice Address - Country:US
Practice Address - Phone:208-939-1035
Practice Address - Fax:208-939-8970
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2012-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8127208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805831200Medicaid
ID805831200Medicaid