Individual
ALI SUP
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
3165 E GREENHURST RD, NAMPA, ID 83686-8655
(208) 463-7300
Mailing address
190 E BANNOCK ST, BOISE, ID 83712-6241
(208) 381-8752
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
MRO-1938
ID
207Q00000X
Family Medicine Physician
Primary
O-1580
ID
Other
Enumeration date
05/15/2020
Last updated
12/23/2025
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