Provider Demographics
NPI:1851334817
Name:BLAUER, WAYNE H (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:H
Last Name:BLAUER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:208-678-2283
Mailing Address - Fax:
Practice Address - Street 1:1501 HILAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2688
Practice Address - Country:US
Practice Address - Phone:208-678-2283
Practice Address - Fax:208-677-6059
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002576000Medicaid
IDDBBE9OtherBLUE CROSS OF IDAHO
ID000010003657OtherBLUE SHIELD OF IDAHO
IDC36926Medicare UPIN
ID1116363Medicare PIN