Healthcare Provider Details

I. General information

NPI: 1003869355
Provider Name (Legal Business Name): CLAIRE MAGNOLO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3399 E LOUISE DR STE 400
MERIDIAN ID
83642-5212
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-4650
  • Fax: 208-706-4651
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-2530
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: