Healthcare Provider Details

I. General information

NPI: 1508514456
Provider Name (Legal Business Name): TAKAHISA KOIDE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CALDWELL BLVD
NAMPA ID
83651-1707
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-6567
  • Fax:
Mailing address:
  • Phone: 208-955-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2208
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: