Provider Demographics
NPI:1790770246
Name:ANSTINE, SUZANNE M (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:ANSTINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-343-7501
Mailing Address - Fax:208-336-8248
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:SUITE 302
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6267
Practice Address - Country:US
Practice Address - Phone:208-343-7501
Practice Address - Fax:208-336-8248
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8468207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20002407Medicare PIN
ID20002628Medicare PIN