Healthcare Provider Details

I. General information

NPI: 1992215545
Provider Name (Legal Business Name): JASON E KOLB PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 N CURTIS RD STE 201
BOISE ID
83706
US

IV. Provider business mailing address

3340 E GOLDSTONE DR
MERIDIAN ID
83642
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-3300
  • Fax: 208-302-3355
Mailing address:
  • Phone: 208-302-3300
  • Fax: 208-302-3355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA202158
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1545
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: