Provider Demographics
NPI:1154188050
Name:HALCYON INFUSIONS & THERAPEUTICS, PLLC
Entity type:Organization
Organization Name:HALCYON INFUSIONS & THERAPEUTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:208-546-3650
Mailing Address - Street 1:1123 12TH AVE RD # 325
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5738
Mailing Address - Country:US
Mailing Address - Phone:208-546-3650
Mailing Address - Fax:
Practice Address - Street 1:1611 12TH AVE RD STE A
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6182
Practice Address - Country:US
Practice Address - Phone:208-546-3650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty