Individual
KOVIC SHANE BAILEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
775 POLE LINE RD W, TWIN FALLS, ID 83301-5814
(208) 814-8000
(208) 733-9402
Mailing address
190 E BANNOCK ST, BOISE, ID 83712-6241
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
7771540
ID
390200000X
Student in an Organized Health Care Education/Training Program
BP10080618
TX
Other
Enumeration date
04/13/2022
Last updated
06/27/2025
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