Provider Demographics
NPI:1730180092
Name:CABRERA, NANI JANE (DO)
Entity type:Individual
Prefix:DR
First Name:NANI
Middle Name:JANE
Last Name:CABRERA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:1107 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2255
Practice Address - Country:US
Practice Address - Phone:208-452-8700
Practice Address - Fax:208-452-8725
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO27065207Q00000X
IDO0372207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000155Medicare PIN
ORR166816Medicare PIN