Provider Demographics
NPI:1225324361
Name:BOONE, CHRISTOPHER RYAN (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:RYAN
Last Name:BOONE
Suffix:
Gender:M
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:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5601 W CHINDEN BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:ID
Practice Address - Zip Code:83714-1463
Practice Address - Country:US
Practice Address - Phone:208-809-2865
Practice Address - Fax:208-809-2866
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.138833207Q00000X
CODR.0058728207Q00000X
IDM-16455207Q00000X
IAMD-41559207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000152898Medicaid