Provider Demographics
NPI:1386263796
Name:SHUMWAY, NICHOLE BLAIR (DO)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:BLAIR
Last Name:SHUMWAY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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 1:801 POLE LINE RD W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5810
Practice Address - Country:US
Practice Address - Phone:208-814-4100
Practice Address - Fax:208-814-4908
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1848207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine