Provider Demographics
NPI:1801765524
Name:FAJARDO, GABRIEL JR
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:FAJARDO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 W TETON AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-4820
Mailing Address - Country:US
Mailing Address - Phone:208-422-1092
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4599
Practice Address - Country:US
Practice Address - Phone:208-422-1092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-31
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID60578163WG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0100XNursing Service ProvidersRegistered NurseGastroenterology