Healthcare Provider Details

I. General information

NPI: 1780194613
Provider Name (Legal Business Name): KOLT MONTE PIQUET PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 CURLEW DR
AMMON ID
83406-4850
US

IV. Provider business mailing address

1675 CURLEW DR
AMMON ID
83406-4850
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-5319
  • Fax: 208-523-5627
Mailing address:
  • Phone: 208-523-5319
  • Fax: 208-523-5627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1539
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: