Provider Demographics
NPI:1386672228
Name:CHRISTENSEN, SCOTT L (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:L
Last Name:CHRISTENSEN
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 1:333 N 1ST ST STE 260
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6132
Mailing Address - Country:US
Mailing Address - Phone:208-345-3136
Mailing Address - Fax:208-345-0984
Practice Address - Street 1:333 N 1ST ST STE 260
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6132
Practice Address - Country:US
Practice Address - Phone:208-345-3136
Practice Address - Fax:208-345-0984
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7991174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805748600Medicaid
ID37184OtherBLUE CROSS
ID000010028712OtherBLUE SHIELD
ID37184OtherBLUE CROSS
ID805748600Medicaid