Healthcare Provider Details

I. General information

NPI: 1801132980
Provider Name (Legal Business Name): KATIE ELIZABETH VAN LIER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATIE E GIBBONS PA-C

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10255 W OVERLAND RD
BOISE ID
83709-1430
US

IV. Provider business mailing address

3340 E GOLDSTONE DR
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-5600
  • Fax: 208-302-5655
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA08089
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2034
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: