Healthcare Provider Details

I. General information

NPI: 1295680809
Provider Name (Legal Business Name): SANA KASUMOVIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 SYRINGA LN
CALDWELL ID
83605-3052
US

IV. Provider business mailing address

3 MAKIN LN
SUCCASUNNA NJ
07876-1111
US

V. Phone/Fax

Practice location:
  • Phone: 208-850-5111
  • Fax:
Mailing address:
  • Phone: 208-850-5111
  • 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: SANDRA KASUMOVIC
Title or Position: PA-C
Credential: DMSC, MPAS
Phone: 208-850-5111