Provider Demographics
NPI:1235111261
Name:KUESTNER, LAURIE M (MD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:M
Last Name:KUESTNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277381
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2860 CHANNING WAY STE 220
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7541
Practice Address - Country:US
Practice Address - Phone:208-800-6155
Practice Address - Fax:208-800-6158
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID98719662086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0129486Medicaid
IA0129486Medicaid
IAF34970Medicare UPIN