Provider Demographics
NPI:1386921294
Name:COMPREHENSIVE DERMATOLOGY OF IDAHO, PLLC
Entity type:Organization
Organization Name:COMPREHENSIVE DERMATOLOGY OF IDAHO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:OWSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-467-7546
Mailing Address - Street 1:16111 N BRINSON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-5509
Mailing Address - Country:US
Mailing Address - Phone:208-467-7546
Mailing Address - Fax:208-467-7500
Practice Address - Street 1:16111 N BRINSON ST STE 100
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-5509
Practice Address - Country:US
Practice Address - Phone:208-467-7546
Practice Address - Fax:208-467-7500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-05
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8483207N00000X
IDPA280363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H66782Medicare UPIN
P62671Medicare UPIN