Provider Demographics
NPI:1265635171
Name:ASTHMA & ALLERGY OF IDAHO
Entity Type:Organization
Organization Name:ASTHMA & ALLERGY OF IDAHO
Other - Org Name:ASTHMA & ALLERGY OF IDAHO MID LEVEL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-734-6091
Mailing Address - Street 1:1502 LOCUST ST N STE 600
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4164
Mailing Address - Country:US
Mailing Address - Phone:208-734-6091
Mailing Address - Fax:208-734-4654
Practice Address - Street 1:1502 LOCUST ST N STE 600
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4164
Practice Address - Country:US
Practice Address - Phone:208-734-6091
Practice Address - Fax:208-734-4654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty