Provider Demographics
NPI:1922298678
Name:AXTELL, ANDREA D (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:D
Last Name:AXTELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:DAWN
Other - Last Name:HALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5995 W STATE ST
Mailing Address - Street 2:STE A
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3085
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:STE 3102
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-706-5100
Practice Address - Fax:208-706-5169
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL17364207R00000X
IDM11047207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine