Healthcare Provider Details

I. General information

NPI: 1821509704
Provider Name (Legal Business Name): LAUREN MEZIERE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

2460 N PLEASANT HILL WAY
BOISE ID
83702-5071
US

V. Phone/Fax

Practice location:
  • Phone: 208-914-1695
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: