Healthcare Provider Details

I. General information

NPI: 1235443193
Provider Name (Legal Business Name): JUSTIN S. NIELSEN PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2985 CORTEZ AVE
IDAHO FALLS ID
83404-7554
US

IV. Provider business mailing address

2985 CORTEZ AVE
IDAHO FALLS ID
83404-7554
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-3373
  • Fax: 208-523-8746
Mailing address:
  • Phone: 208-523-3373
  • Fax: 208-523-8746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002097
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1255
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: