Provider Demographics
NPI:1174051429
Name:CAMPBELL, IAN (DPT)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2195 W HILL RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0622
Mailing Address - Country:US
Mailing Address - Phone:208-850-6995
Mailing Address - Fax:208-323-9752
Practice Address - Street 1:2195 W HILL RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-0622
Practice Address - Country:US
Practice Address - Phone:208-850-6995
Practice Address - Fax:208-323-9752
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-5047225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT-5047OtherPT LICENSE