1538192810 NPI number — ROCKY WADE ELSASSER DPT

Table of content: ROCKY WADE ELSASSER DPT (NPI 1538192810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538192810 NPI number — ROCKY WADE ELSASSER DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELSASSER
Provider First Name:
ROCKY
Provider Middle Name:
WADE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538192810
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2176 E FRANKLIN RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-9024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-288-1155
Provider Business Mailing Address Fax Number:
208-288-0424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
943 N LINDER RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
KUNA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
63634-3395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-922-1719
Provider Business Practice Location Address Fax Number:
208-922-1721
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  49332238-2401 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT-2180 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 807785000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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