Provider Demographics
NPI:1457831745
Name:NEIBAUR, TAIGAN
Entity Type:Individual
Prefix:
First Name:TAIGAN
Middle Name:
Last Name:NEIBAUR
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 1:6871 STAGE COACH RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-1282
Mailing Address - Country:US
Mailing Address - Phone:120-825-1642
Mailing Address - Fax:
Practice Address - Street 1:901 N CURTIS RD STE 204
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1340
Practice Address - Country:US
Practice Address - Phone:208-251-6426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-5861225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0002138122Medicaid