Healthcare Provider Details

I. General information

NPI: 1164777181
Provider Name (Legal Business Name): JOSHUA D KILLPACK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2442 E 25TH ST
IDAHO FALLS ID
83404-7549
US

IV. Provider business mailing address

2325 CORONADO ST
IDAHO FALLS ID
83404-7407
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-4909
  • Fax:
Mailing address:
  • Phone: 208-557-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-985
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: