Provider Demographics
NPI:1528106309
Name:RASMUS, MARK A (MD-PULM/SM)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:RASMUS
Suffix:
Gender:M
Credentials:MD-PULM/SM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E HAWAII AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6011
Mailing Address - Country:US
Mailing Address - Phone:208-463-3000
Mailing Address - Fax:208-463-3064
Practice Address - Street 1:7272 POTOMAC
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-884-2922
Practice Address - Fax:208-463-3044
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9630174400000X
IDM9630207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010157357OtherBLUE SHIELD
ID76944OtherBLUE CROSS
ID807530600Medicaid
ID807530600Medicaid