Provider Demographics
NPI:1023404811
Name:VARGAS, ANNIS WAKELEE (MD)
Entity type:Individual
Prefix:
First Name:ANNIS
Middle Name:WAKELEE
Last Name:VARGAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:W
Other - Last Name:BLEDSOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-5800
Mailing Address - Fax:208-302-5855
Practice Address - Street 1:1072 N LIBERTY STREET
Practice Address - Street 2:STE 203
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83701
Practice Address - Country:US
Practice Address - Phone:208-302-5800
Practice Address - Fax:208-302-5855
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10077801-1205208000000X
UT10077801-8905208000000X
IDM-14080208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics