Provider Demographics
NPI:1780324483
Name:AGUAYO-ORTEGA, RICKY ANDRES
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:ANDRES
Last Name:AGUAYO-ORTEGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:
Mailing Address - Fax:
Practice Address - Street 1:701 E PARKCENTER BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6528
Practice Address - Country:US
Practice Address - Phone:208-381-6500
Practice Address - Fax:208-381-6505
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9844207Q00000X
ID2871955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine