Provider Demographics
NPI:1700076619
Name:LAZZARO, NICHOLAS A (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:LAZZARO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:115 W MAIN STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-433-9466
Mailing Address - Fax:208-433-1149
Practice Address - Street 1:190 E BANNOCK
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-381-2094
Practice Address - Fax:208-381-1791
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010822512085R0202X
IDM-110012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology