Provider Demographics
NPI:1326496910
Name:ADVANCED FOOT & ANKLE OF MAGIC VALLEY, PLLC
Entity Type:Organization
Organization Name:ADVANCED FOOT & ANKLE OF MAGIC VALLEY, PLLC
Other - Org Name:ADVANCED FOOT & ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:WETTSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-731-6321
Mailing Address - Street 1:176 FALLS AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-2306
Mailing Address - Country:US
Mailing Address - Phone:208-731-6321
Mailing Address - Fax:208-944-0430
Practice Address - Street 1:176 FALLS AVE STE 200
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-2306
Practice Address - Country:US
Practice Address - Phone:208-731-6321
Practice Address - Fax:208-944-0430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-215213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20001268Medicare PIN