Provider Demographics
NPI:1811924616
Name:KLEIN, NICOLE KARIN (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:KARIN
Last Name:KLEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 E IDAHO ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6202
Practice Address - Country:US
Practice Address - Phone:208-338-0148
Practice Address - Fax:208-336-4027
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0628207R00000X
NMMD 2005-0628207RI0200X
IDM-13558207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM45134201Medicaid
NM349534605Medicare ID - Type Unspecified