Healthcare Provider Details

I. General information

NPI: 1376876599
Provider Name (Legal Business Name): JONATHAN B PITTARD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 CHENEY DR W STE 200
TWIN FALLS ID
83301-4278
US

IV. Provider business mailing address

243 CHENEY DR W
TWIN FALLS ID
83301-4277
US

V. Phone/Fax

Practice location:
  • Phone: 208-736-7422
  • Fax: 208-736-8905
Mailing address:
  • Phone: 208-736-7422
  • Fax: 208-736-8905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA804
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: