Provider Demographics
NPI:1427138734
Name:ASTHMA & ALLERGY OF IDAHO PLLC
Entity type:Organization
Organization Name:ASTHMA & ALLERGY OF IDAHO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-734-6091
Mailing Address - Street 1:1502 LOCUST ST N STE 600
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4164
Mailing Address - Country:US
Mailing Address - Phone:208-734-6091
Mailing Address - Fax:208-734-4654
Practice Address - Street 1:1502 LOCUST ST N STE 600
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4164
Practice Address - Country:US
Practice Address - Phone:208-734-6091
Practice Address - Fax:208-734-4654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002736101Medicaid
ID807562300Medicaid
ID002736102Medicaid
ID002736105Medicaid
ID002736100Medicaid
ID002736200Medicaid
ID002736104Medicaid
ID002736202Medicaid
ID002736103Medicaid
ID807562301Medicaid
ID807562300Medicaid
ID002736200Medicaid
ID002736100Medicaid
ID807562301Medicaid
1377091Medicare PIN
1377093Medicare PIN
IDQ24628Medicare UPIN
IDF71211Medicare UPIN
ID002736105Medicaid
ID002736104Medicaid