Healthcare Provider Details

I. General information

NPI: 1467703728
Provider Name (Legal Business Name): NICHOLAS EUGENE GARVER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S 23RD ST
BOISE ID
83702-9100
US

IV. Provider business mailing address

300 S 23RD ST
BOISE ID
83702-9100
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-3512
  • Fax: 208-344-4898
Mailing address:
  • Phone: 970-319-9539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1364
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: