Provider Demographics
NPI:1518042340
Name:BARNES, PENELOPE DARELL
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:DARELL
Last Name:BARNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5966 W CURTISIAN AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8801
Practice Address - Country:US
Practice Address - Phone:208-302-5480
Practice Address - Fax:208-302-5455
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMC-2512207RI0200X
WAMD00042437207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8451163Medicaid
308120OtherINTERNAL ID-MOTOR VEHICLE ID
308120OtherINTERNAL ID-MOTOR VEHICLE ID
8859334Medicare ID - Type Unspecified