Healthcare Provider Details

I. General information

NPI: 1275936981
Provider Name (Legal Business Name): SHAYLAN PEASE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6052 W STATE ST
BOISE ID
83703-2739
US

IV. Provider business mailing address

9155 SW BARNES RD SUITE 210
PORTLAND OR
97225-6625
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-7799
  • Fax: 208-322-8095
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1509
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: