Provider Demographics
NPI:1821108317
Name:RILEY, MARI A (MD)
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:A
Last Name:RILEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARI
Other - Middle Name:ANN
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:215 E HAWAII AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6011
Mailing Address - Country:US
Mailing Address - Phone:208-463-3000
Mailing Address - Fax:208-463-3044
Practice Address - Street 1:875 S VANGUARD WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7552
Practice Address - Country:US
Practice Address - Phone:208-463-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR49628207Q00000X
WI46613207Q00000X
IDM-13163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34576000Medicaid
COCOA108400Medicare PIN
WI34576000Medicaid
COCOA108400Medicare PIN