Healthcare Provider Details

I. General information

NPI: 1033935093
Provider Name (Legal Business Name): KALIN DANIAL LISTER STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8971 W OVERLAND RD
BOISE ID
83709-1651
US

IV. Provider business mailing address

227 SUNRISE RIM RD
NAMPA ID
83686-8325
US

V. Phone/Fax

Practice location:
  • Phone: 208-378-4288
  • Fax: 208-378-4297
Mailing address:
  • Phone: 208-912-3307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9871643
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: