Active NPI
Brody George Yardumian
- Physician Assistant
- Boise, ID
National Provider Identifier
1801439815
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- PA-1844
- Practice address
- 1475 N Cole Rd
Boise, ID 83704-8537 - Phone
- (208) 955-6500
- Fax
- (208) 955-6503
- NPI assigned
- Oct 22, 2019
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 57238 | CA | |
| Physician Assistant | 363A00000X | PA-1844 | ID | Primary |
Addresses
Primary practice location
1475 N Cole Rd
Boise, ID 83704-8537
Mailing address
PO Box 191050
Boise, ID 83719-1050
Phone (208) 955-6500
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 57238 | CA | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1571702400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1625184000000",
"number": "1801439815",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 191050",
"city": "BOISE",
"state": "ID",
"postal_code": "837191050",
"telephone_number": "208-955-6500"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1475 N COLE RD",
"city": "BOISE",
"state": "ID",
"postal_code": "837048537",
"telephone_number": "208-955-6500",
"fax_number": "208-955-6503"
}
],
"practiceLocations": [],
"basic": {
"last_name": "YARDUMIAN",
"first_name": "BRODY",
"middle_name": "GEORGE",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2019-10-22",
"last_updated": "2021-07-02",
"certification_date": "2021-07-02",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "CA",
"license": "57238",
"primary": false
},
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "ID",
"license": "PA-1844",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Boise, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 2, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.