Healthcare Provider Details

I. General information

NPI: 1588227656
Provider Name (Legal Business Name): TRACI H PERMENTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 N ALLUMBAUGH ST
BOISE ID
83704-9208
US

IV. Provider business mailing address

PO BOX 16303
BOISE ID
83715-6303
US

V. Phone/Fax

Practice location:
  • Phone: 208-888-5848
  • Fax:
Mailing address:
  • Phone: 713-858-1040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1717
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: