Healthcare Provider Details

I. General information

NPI: 1073022778
Provider Name (Legal Business Name): KIMBERLY DOLECHECK TVERDY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY JEANNE DOLECHECK

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 08/19/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 POLE LINE RD W STE 203
TWIN FALLS ID
83301-5820
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-8300
  • Fax:
Mailing address:
  • Phone: 208-381-8752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1524
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: