Healthcare Provider Details

I. General information

NPI: 1841875895
Provider Name (Legal Business Name): LAURA ANNE BARCELO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 W 1ST S
REXBURG ID
83440-1810
US

IV. Provider business mailing address

636 N 2743 E
ROBERTS ID
83444-5068
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-8883
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2037
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA-2037
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: