Healthcare Provider Details

I. General information

NPI: 1487944716
Provider Name (Legal Business Name): NICHOLAS A. HUTT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 10/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 N 2ND ST SUITE 103
BOISE ID
83702-6077
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-4700
  • Fax: 208-381-4977
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-901
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: