Provider Demographics
NPI:1972275501
Name:BOSTIAN, ROBERTA J (AGACNP)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:J
Last Name:BOSTIAN
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7407
Mailing Address - Country:US
Mailing Address - Phone:208-557-2700
Mailing Address - Fax:
Practice Address - Street 1:765 S UTAH AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-5093
Practice Address - Country:US
Practice Address - Phone:208-525-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID68854363LA2100X
UT12751401-4405363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care