Provider Demographics
NPI:1710166004
Name:L. WILLIAM D. NOWIERSKI, M.D. PA
Entity Type:Organization
Organization Name:L. WILLIAM D. NOWIERSKI, M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:L. WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:NOWIERSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-343-5910
Mailing Address - Street 1:100 WARM SPRINGS AVE
Mailing Address - Street 2:STE. A
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6243
Mailing Address - Country:US
Mailing Address - Phone:208-343-5910
Mailing Address - Fax:208-384-8562
Practice Address - Street 1:100 WARM SPRINGS AVE
Practice Address - Street 2:STE. A
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6243
Practice Address - Country:US
Practice Address - Phone:208-343-5910
Practice Address - Fax:208-384-8562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4341261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID4341-4OtherBLUE CROSS OF IDAHO
ID4341-4OtherBLUE CROSS OF IDAHO
ID1114483Medicare PIN