Healthcare Provider Details

I. General information

NPI: 1154626323
Provider Name (Legal Business Name): NICHOLAS J BOX P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2011
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY
POCATELLO ID
83201-5175
US

IV. Provider business mailing address

P.O. BOX 4168
POCATELLO ID
83205-4168
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-2481
  • Fax: 208-239-3691
Mailing address:
  • Phone: 208-239-1035
  • Fax: 208-239-3626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-877
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: