Provider Demographics
NPI:1730712266
Name:MATSUMURO, GAYLE
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:MATSUMURO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GAYLE
Other - Middle Name:
Other - Last Name:MATSUMURO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP
Mailing Address - Street 1:413 N ALLUMBAUGH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9219
Mailing Address - Country:US
Mailing Address - Phone:208-323-1125
Mailing Address - Fax:208-323-1905
Practice Address - Street 1:413 N ALLUMBAUGH ST STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9219
Practice Address - Country:US
Practice Address - Phone:208-323-1125
Practice Address - Fax:208-323-1905
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID64061363LP0808X
ID26983363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health