Healthcare Provider Details

I. General information

NPI: 1386821759
Provider Name (Legal Business Name): NATHANIEL ASHBY VAN VALIN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N SYRINGA ST STE 100
POST FALLS ID
83854-5275
US

IV. Provider business mailing address

1593 E POLSTON AVE
POST FALLS ID
83854-5326
US

V. Phone/Fax

Practice location:
  • Phone: 208-262-2600
  • Fax: 208-262-2700
Mailing address:
  • Phone: 208-262-2498
  • Fax: 208-262-7461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1482
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: