Individual
BLAKE D NIEDERHAUSER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
190 E BANNOCK ST, BOISE, ID 83712-6241
(208) 381-2094
(208) 381-1791
Mailing address
PO BOX 1108, CORVALLIS, OR 97339-1108
(208) 381-2094
(208) 381-1791
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
104451
MN
2085R0202X
Diagnostic Radiology Physician
52314
MN
2085R0202X
Diagnostic Radiology Physician
Primary
M-12384
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
ENROLLED
—
IA
05
—
ENROLLED
—
MN
Enumeration date
07/08/2008
Last updated
01/10/2018
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