Basic Information
| Provider Information | |||||||||
| NPI: | 1073879185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHLEBECK | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | DYLAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 E HAWAII AVE | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836866011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084633000 | ||||||||
| FaxNumber: | 2084633055 | ||||||||
| Practice Location | |||||||||
| Address1: | 875 S VANGUARD WAY | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836428540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084633000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2012 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | A148489 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0801X | A148489 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207XX0801X | M-14245 | ID | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207X00000X | M-14245 | ID | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.