Healthcare Provider Details

I. General information

NPI: 1235565128
Provider Name (Legal Business Name): JULIE MACGREGOR PA-C, LE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2013
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 S BALTIC PL STE 109
MERIDIAN ID
83642-5935
US

IV. Provider business mailing address

82 S BALTIC PL STE 109
MERIDIAN ID
83642-5935
US

V. Phone/Fax

Practice location:
  • Phone: 86-002-6792
  • Fax:
Mailing address:
  • Phone: 208-600-2679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-1613
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA165087
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberEE-285937
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: