Healthcare Provider Details

I. General information

NPI: 1649235581
Provider Name (Legal Business Name): MICHAEL J TRIMBLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6165 W EMERALD STREET
BOISE ID
83704
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-3500
  • Fax: 208-302-3555
Mailing address:
  • Phone: 208-302-3500
  • Fax: 208-302-3555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1602
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number757
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: