Provider Demographics
NPI:1861029159
Name:SHANKS, ROBERT PAUL (FNP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:PAUL
Last Name:SHANKS
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:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:082-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:315 E ELM ST STE 100
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4858
Practice Address - Country:US
Practice Address - Phone:208-302-7150
Practice Address - Fax:208-302-7192
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202000267NP-PP363LA2100X
IDNP-75863363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care