Basic Information
| Provider Information | |||||||||
| NPI: | 1619263373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FITZMAURICE | ||||||||
| OtherFirstName: | MAUREEN | ||||||||
| OtherMiddleName: | BRENNA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087068526 | ||||||||
| FaxNumber: | 2065687043 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 MADISON ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063866111 | ||||||||
| FaxNumber: | 2083866113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2011 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MR-1181 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | M-11816 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 60471517 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1619263373 | 05 | ID | MEDICAID |