Healthcare Provider Details

I. General information

NPI: 1164596128
Provider Name (Legal Business Name): ANGHARAD SUPE LYON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ISU STUDENT HEALTH CTR 921 S. 8TH ST.
POCATELLO ID
83209-0001
US

IV. Provider business mailing address

69 FOOTHILL BLVD
POCATELLO ID
83204-4063
US

V. Phone/Fax

Practice location:
  • Phone: 208-282-2330
  • Fax: 208-282-4036
Mailing address:
  • Phone: 208-282-2330
  • Fax: 208-282-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPA-365
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: