Healthcare Provider Details

I. General information

NPI: 1477286201
Provider Name (Legal Business Name): SAMANTHA ANNE MCCAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2022
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6051 W EMERALD ST
BOISE ID
83704-8969
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-5150
  • Fax: 208-302-5155
Mailing address:
  • Phone: 208-302-9342
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8761978
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: