Organization
ASTHMA & ALLERGY OF IDAHO PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ANDREW WICKERN (CREDENTIALING SPECIALIST)
(208) 734-6091
Entity
Organization
Contact information
Practice address
1502 LOCUST ST N STE 600, TWIN FALLS, ID 83301-4164
(208) 734-6091
(208) 734-4654
Mailing address
1502 LOCUST ST N STE 600, TWIN FALLS, ID 83301-4164
(208) 734-6091
(208) 734-4654
Taxonomy
Speciality
Code
Description
License number
State
207KA0200X
Allergy Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002736100
—
ID
05
—
002736101
—
ID
05
—
002736102
—
ID
05
—
002736103
—
ID
05
—
002736104
—
ID
05
—
002736105
—
ID
05
—
002736200
—
ID
05
—
002736202
—
ID
05
—
807562300
—
ID
05
—
807562301
—
ID
Enumeration date
10/17/2006
Last updated
01/14/2021
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