Healthcare Provider Details

I. General information

NPI: 1265800742
Provider Name (Legal Business Name): LAURA MARIE GIFFORD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA MARIE HILDEBRANDT PA-C

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 6TH ST
LEWISTON ID
83501-2431
US

IV. Provider business mailing address

415 6TH STREET EMERGENCY DEPARTMENT
LEWISTON ID
83501-2431
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-2511
  • Fax:
Mailing address:
  • Phone: 208-799-5457
  • Fax: 208-799-5766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61022472
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1434
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: