Provider Demographics
NPI:1619545936
Name:AVILA, ADRIAN (RN, NP)
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:AVILA
Suffix:
Gender:M
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 BADIOLA ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4389
Mailing Address - Country:US
Mailing Address - Phone:541-539-1124
Mailing Address - Fax:
Practice Address - Street 1:314 BADIOLA ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4389
Practice Address - Country:US
Practice Address - Phone:541-539-1124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID53602363LP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID53602OtherIDAHO BOARD OF NURSING