Healthcare Provider Details

I. General information

NPI: 1679918536
Provider Name (Legal Business Name): JOEL J BURCH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2013
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 N HAPPY VALLEY RD
NAMPA ID
83687-5280
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-809-2869
  • Fax:
Mailing address:
  • Phone: 208-955-6500
  • Fax: 208-955-6503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-1066
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: