Provider Demographics
NPI:1922298678
Name:AXTELL, ANDREA D (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:D
Last Name:AXTELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:DAWN
Other - Last Name:HALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-302-9342
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:323 E RIVERSIDE DR STE 224
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6865
Practice Address - Country:US
Practice Address - Phone:208-302-6000
Practice Address - Fax:208-302-6055
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL17364207R00000X
IDM11047207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine