Healthcare Provider Details

I. General information

NPI: 1699842021
Provider Name (Legal Business Name): MARLO PICHARDO PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARLO SMITH PA

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2757 S GOSHEN WAY
BOISE ID
83709-8506
US

IV. Provider business mailing address

2757 S GOSHEN WAY
BOISE ID
83709-8506
US

V. Phone/Fax

Practice location:
  • Phone: 208-740-8797
  • Fax: 530-237-0772
Mailing address:
  • Phone: 87-408-7972
  • Fax: 530-237-0772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9102903
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1898
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: