Healthcare Provider Details

I. General information

NPI: 1659004869
Provider Name (Legal Business Name): CAMERON J WYCHANKO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9292 W BARNES DR
BOISE ID
83709-1554
US

IV. Provider business mailing address

1650 S TOPAZ WAY
MERIDIAN ID
83642-4474
US

V. Phone/Fax

Practice location:
  • Phone: 208-795-3515
  • Fax:
Mailing address:
  • Phone: 208-605-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2439
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: