Provider Demographics
NPI:1164121562
Name:MAUGHAN, GUNNAR HARRISON (MSPO, CPO)
Entity Type:Individual
Prefix:
First Name:GUNNAR
Middle Name:HARRISON
Last Name:MAUGHAN
Suffix:
Gender:M
Credentials:MSPO, CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 W RIVER HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5120
Mailing Address - Country:US
Mailing Address - Phone:208-866-5177
Mailing Address - Fax:
Practice Address - Street 1:9632 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9762
Practice Address - Country:US
Practice Address - Phone:208-866-5177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies