Eagle Dermatology, PLLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

O-1094 Issued in ID

Legal business name

EAGLE DERMATOLOGY, PLLC

Practice address

323 E Riverside Dr Ste 234
Eagle, ID 83616-6865

Phone

(208) 391-7210

Fax

(208) 391-2130

NPI assigned

Feb 6, 2018

Organization subpart

No

Name

Mrs. Jennifer Annette Guerrero

Title

Practice Manager

Phone

(208) 391-7210

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Gabriel Guerrero, D.O.

  • Dermatology Physician
  • Eagle, ID
  • NPI 1184080210

  Dermatology, ID

  Medicare reassignment Care Compare group NPD
• Lori Katherine Ebinger, PA-C

  • Physician Assistant
  • Eagle, ID
  • NPI 1629446661

  ID

  Medicare reassignment Care Compare group
• Victoria R Rice

  • Physician Assistant
  • Eagle, ID
  • NPI 1588317937

  ID

  Medicare reassignment Care Compare group
• Scott Ward Webster, DNP, ARNP, FNP-C

  • Family Nurse Practitioner
  • Orem, UT
  • NPI 1275916785

  ID

  Medicare reassignment NPD
• Joanna Dziewa, APRN-CNP

  • Family Nurse Practitioner
  • Boise, ID
  • NPI 1699409540
  NPD (past)

Medicare fee-for-service enrollment

Enrolled in ID

Locations

Interoperability endpoints

• FHIR API: https://app.meldrx.com/api/fhir/ez_00113

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Feb 6, 2018.

{
    "created_epoch": "1517875200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1517875200000",
    "number": "1417456385",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "372 S EAGLE RD # 126",
            "city": "EAGLE",
            "state": "ID",
            "postal_code": "836165908",
            "telephone_number": "208-391-7210",
            "fax_number": "208-391-2130"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "323 E RIVERSIDE DR STE 234",
            "city": "EAGLE",
            "state": "ID",
            "postal_code": "836166865",
            "telephone_number": "208-391-7210",
            "fax_number": "208-391-2130"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAGLE DERMATOLOGY, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-02-06",
        "last_updated": "2018-02-06",
        "status": "A",
        "authorized_official_last_name": "GUERRERO",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "ANNETTE",
        "authorized_official_title_or_position": "PRACTICE MANAGER",
        "authorized_official_telephone_number": "208-391-7210",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": "ID",
            "license": "O-1094",
            "primary": true
        },
        {
            "code": "207ND0101X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology, MOHS-Micrographic Surgery",
            "state": "ID",
            "license": "O-1094",
            "primary": false
        },
        {
            "code": "207ND0900X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology, Dermatopathology",
            "state": "ID",
            "license": "O-1094",
            "primary": false
        },
        {
            "code": "207NI0002X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology, Clinical & Laboratory Dermatological Immunology",
            "state": "ID",
            "license": "O-1094",
            "primary": false
        },
        {
            "code": "207NP0225X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology, Pediatric Dermatology",
            "state": "ID",
            "license": "O-1094",
            "primary": false
        },
        {
            "code": "207NS0135X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology, Procedural Dermatology",
            "state": "ID",
            "license": "O-1094",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jacob Gary Dyer
• Aaron Dykstra, NP
• Eagle Chiropractic PC
• Eagle Cramer Chiropractic, P.a.
• Eagle Dental Partnership PLLC
• Eagle Family Medicine P a
• Eagle Healthcare LLC
• Eagle Healthcare LLC
• Eagle Healthcare LLC
• Eagle Hearing LLC

• All providers in Eagle, ID
• Dermatology Physician in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 6, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.