Healthcare Provider Details

I. General information

NPI: 1184134843
Provider Name (Legal Business Name): ERIN MARIE SHUMARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3280 E LANARK DR
MERIDIAN ID
83642-5982
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-4400
  • Fax: 208-377-4416
Mailing address:
  • Phone: 208-985-1399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1542
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: