Basic Information
| Provider Information | |||||||||
| NPI: | 1659782829 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WERTZLER | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | JANEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 N RAYMOND ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837049251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085142500 | ||||||||
| FaxNumber: | 2083752217 | ||||||||
| Practice Location | |||||||||
| Address1: | 2275 S EAGLE RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085142520 | ||||||||
| FaxNumber: | 2083752217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | M-13116 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MRM-1403 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1659782829 | 05 | ID | MEDICAID |