Healthcare Provider Details

I. General information

NPI: 1710362710
Provider Name (Legal Business Name): ANDREW P SWENSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6165 W EMERALD
BOISE ID
83704
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-3500
  • Fax: 208-302-3555
Mailing address:
  • Phone: 208-302-3500
  • Fax: 208-302-3555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-1477
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: