Healthcare Provider Details

I. General information

NPI: 1578808333
Provider Name (Legal Business Name): ANDREW WILLIAM BAUKOL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2012
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2939 W EXCURSION LN
MERIDIAN ID
83642-5308
US

IV. Provider business mailing address

2939 W EXCURSION LN
MERIDIAN ID
83642-5308
US

V. Phone/Fax

Practice location:
  • Phone: 208-385-7711
  • Fax:
Mailing address:
  • Phone: 208-385-7711
  • Fax: 208-385-0346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: