Healthcare Provider Details

I. General information

NPI: 1164905865
Provider Name (Legal Business Name): RACHEL ENSLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RACHEL LUCIA

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 S MAIN ST STE 110
MOSCOW ID
83843-2695
US

IV. Provider business mailing address

111 N WASHINGTON ST STE 8
MOSCOW ID
83843-2802
US

V. Phone/Fax

Practice location:
  • Phone: 208-813-7519
  • Fax: 208-813-7524
Mailing address:
  • Phone: 208-813-7519
  • Fax: 208-813-7524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: