Healthcare Provider Details

I. General information

NPI: 1932784386
Provider Name (Legal Business Name): SKYLER ELLSWORTH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 S MILLENIUM WAY STE 100
MERIDIAN ID
83642-6457
US

IV. Provider business mailing address

2840 S MERIDIAN RD
MERIDIAN ID
83642-7960
US

V. Phone/Fax

Practice location:
  • Phone: 208-884-3376
  • Fax: 208-884-0858
Mailing address:
  • Phone: 208-593-6393
  • Fax: 208-593-6402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-2207
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: