Healthcare Provider Details

I. General information

NPI: 1962944272
Provider Name (Legal Business Name): AXIS SPINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2016
Last Update Date: 04/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1641 E POLSTON AVE SUITE 101
POST FALLS ID
83854-7852
US

IV. Provider business mailing address

1641 E POLSTON AVE SUITE 101
POST FALLS ID
83854-7852
US

V. Phone/Fax

Practice location:
  • Phone: 208-457-4208
  • Fax: 208-457-4197
Mailing address:
  • Phone: 208-457-4208
  • Fax: 208-457-4197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JESSICA JAMESON
Title or Position: MD / OWNER
Credential:
Phone: 208-457-4208