Provider Demographics
NPI:1093026718
Name:CAREY, KATHLEEN (DO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:CAREY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:VANHOOMISSEN
Other - Suffix:
Other - Last Name Type:Former Name
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:
Mailing Address - Fax:
Practice Address - Street 1:701 E PARKCENTER BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6528
Practice Address - Country:US
Practice Address - Phone:208-381-6500
Practice Address - Fax:208-381-6505
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK8020204D00000X, 207Q00000X
MI5315046213207Q00000X
IDO-1791207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1618463Medicaid
AK1618463Medicaid