Healthcare Provider Details

I. General information

NPI: 1184142606
Provider Name (Legal Business Name): BRIAN KEVIN TAFT PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2017
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 W PRAIRIE AVE
COEUR D ALENE ID
83815-8780
US

IV. Provider business mailing address

PO BOX 1517
PENDLETON OR
97801-0410
US

V. Phone/Fax

Practice location:
  • Phone: 208-209-0288
  • Fax: 208-209-0289
Mailing address:
  • Phone: 541-278-4332
  • Fax: 541-278-8349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60913443
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-2587
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: