Provider Demographics
NPI:1770651309
Name:MAXWELL, NOAH D (PT)
Entity Type:Individual
Prefix:
First Name:NOAH
Middle Name:D
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5521 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3337
Mailing Address - Country:US
Mailing Address - Phone:208-853-6220
Mailing Address - Fax:208-853-0554
Practice Address - Street 1:5521 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-3337
Practice Address - Country:US
Practice Address - Phone:208-853-6220
Practice Address - Fax:208-853-0554
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2140225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8079161Medicaid
IDP00443133OtherRETIRED RAILROAD MEDICARE
ID8079161Medicaid