Provider Demographics
NPI:1639535792
Name:GORIUP, ANITA MARIE (REEGT)
Entity Type:Individual
Prefix:MS
First Name:ANITA
Middle Name:MARIE
Last Name:GORIUP
Suffix:
Gender:F
Credentials:REEGT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2173 CALICO DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2369
Mailing Address - Country:US
Mailing Address - Phone:208-589-4210
Mailing Address - Fax:
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7533
Practice Address - Country:US
Practice Address - Phone:208-529-6147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG