Provider Demographics
NPI:1578547543
Name:ZASTROW, CONNIE L (MD)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:ZASTROW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1075 N CURTIS RD STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1348
Practice Address - Country:US
Practice Address - Phone:208-302-2800
Practice Address - Fax:208-302-2825
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD601508432086S0129X
ID57718752086S0129X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1578547543Medicaid
WA0262756OtherL&I AND CRIME VICTIMS
WA0026ZAOtherREGENCE
WAG8892931Medicare PIN
WA1578547543Medicaid