Healthcare Provider Details

I. General information

NPI: 1861386443
Provider Name (Legal Business Name): BRIEANNA LEE JUNG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W IRONWOOD DR STE 341
COEUR D ALENE ID
83814-4404
US

IV. Provider business mailing address

9702 N HAUSER LAKE RD
HAUSER ID
83854-5528
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-5200
  • Fax:
Mailing address:
  • Phone: 208-704-2604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number8671366
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: