Provider Demographics
NPI:1437868999
Name:FREMONT, WILLIAM TRAVIS
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:TRAVIS
Last Name:FREMONT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 S FIVE MILE RD # 190893
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1305
Mailing Address - Country:US
Mailing Address - Phone:208-817-0303
Mailing Address - Fax:
Practice Address - Street 1:11298 W STALLION LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5236
Practice Address - Country:US
Practice Address - Phone:208-817-0303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-23
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver