Healthcare Provider Details

I. General information

NPI: 1447227293
Provider Name (Legal Business Name): TROY A LANDES PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 MAIN
MARSING ID
83639
US

IV. Provider business mailing address

211 16TH AVE N PO BOX 9
NAMPA ID
83687-4058
US

V. Phone/Fax

Practice location:
  • Phone: 208-896-4159
  • Fax: 208-896-4917
Mailing address:
  • Phone: 208-461-7149
  • Fax: 208-467-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA050718
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: