Healthcare Provider Details

I. General information

NPI: 1487804589
Provider Name (Legal Business Name): RORY STEPHEN O'CONNOR PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2008
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST # 111
BOISE ID
83702
US

IV. Provider business mailing address

500 W FORT ST # 111
BOISE ID
83702
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1325
  • Fax: 208-422-1319
Mailing address:
  • Phone: 208-422-1325
  • Fax: 208-422-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-770
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: