Provider Demographics
NPI:1700828241
Name:HOUSE, ANGELA L (DO)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:HOUSE
Suffix:
Gender:F
Credentials:DO
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 191050
Mailing Address - Street 2:SUITE 250
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-985-1399
Mailing Address - Fax:208-955-6501
Practice Address - Street 1:5601 W CHINDEN BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:ID
Practice Address - Zip Code:83714-1463
Practice Address - Country:US
Practice Address - Phone:208-809-2865
Practice Address - Fax:208-809-2866
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO0370207Q00000X
ID0-0370207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807273000Medicaid
ID807273000Medicaid
ID1131158Medicare ID - Type Unspecified