Provider Demographics
NPI:1275767519
Name:EDVALSON, NOAH BLUE (DC, FIAMA)
Entity Type:Individual
Prefix:DR
First Name:NOAH
Middle Name:BLUE
Last Name:EDVALSON
Suffix:
Gender:M
Credentials:DC, FIAMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3224 N MAPLE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4214
Mailing Address - Country:US
Mailing Address - Phone:208-629-5374
Mailing Address - Fax:208-629-5394
Practice Address - Street 1:3224 N MAPLE GROVE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4214
Practice Address - Country:US
Practice Address - Phone:208-629-5374
Practice Address - Fax:208-629-5394
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1368111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808-3540-00Medicaid
1678908Medicare PIN