Healthcare Provider Details

I. General information

NPI: 1245310846
Provider Name (Legal Business Name): BOYD ERIC LARSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 02/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S WOODRUFF AVE
IDAHO FALLS ID
83401-5285
US

IV. Provider business mailing address

1115 LANE 12
LOVELL WY
82431
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-9111
  • Fax: 208-542-9114
Mailing address:
  • Phone: 307-548-5200
  • Fax: 307-548-5224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberML1456587
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: