Healthcare Provider Details

I. General information

NPI: 1710537964
Provider Name (Legal Business Name): DONALD E SANFORD JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4815 CLEVELAND BLVD
CALDWELL ID
83605-6501
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-455-3545
  • Fax:
Mailing address:
  • Phone: 208-955-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1779
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: