Provider Demographics
NPI:1841800943
Name:SIMPSON, CHARLES BRYAN (FNP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRYAN
Last Name:SIMPSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9891 W MREN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-4723
Mailing Address - Country:US
Mailing Address - Phone:208-484-7804
Mailing Address - Fax:
Practice Address - Street 1:267 N CANYON DR
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-5500
Practice Address - Country:US
Practice Address - Phone:208-934-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID16540146L00000X
ID44491163W00000X, 163WF0300X
ID66241363LF0000X, 363L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No163W00000XNursing Service ProvidersRegistered Nurse
No163WF0300XNursing Service ProvidersRegistered NurseFlight
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program