Provider Demographics
NPI:1831736487
Name:STANWORTH, WESTON
Entity type:Individual
Prefix:
First Name:WESTON
Middle Name:
Last Name:STANWORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7550 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9015
Mailing Address - Country:US
Mailing Address - Phone:208-375-0765
Mailing Address - Fax:
Practice Address - Street 1:1005 W AIRBASE RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3339
Practice Address - Country:US
Practice Address - Phone:208-587-1784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist