Provider Demographics
NPI:1164463964
Name:ADRIAN, LOIS (MD)
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:
Last Name:ADRIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LOIS
Other - Middle Name:
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:1450 AVIATION DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8785
Practice Address - Country:US
Practice Address - Phone:208-788-3434
Practice Address - Fax:208-788-2025
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4330207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000520200Medicaid
ID080147002OtherRR MEDICARE
ID080147002OtherRR MEDICARE
ID1114587Medicare ID - Type UnspecifiedMEDICARE NUMBER