Healthcare Provider Details

I. General information

NPI: 1417066143
Provider Name (Legal Business Name): CHRISTOPHER D GUNDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 W CHINDEN BLVD
GARDEN CITY ID
83714-1463
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-809-2865
  • Fax: 208-809-2866
Mailing address:
  • Phone: 208-955-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-742
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10004402
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: