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General NPI Number Information
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NPI Number | 1033935093
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Entity Type | Individual
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Provider Name | KALIN DANIAL LISTER STUDENT
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Gender | Male
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Dates
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Enumeration Date | 11/25/2024
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Last Update Date | 03/05/2025
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Provider Practice Location Address
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Address Line | 8971 W OVERLAND RD
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City | BOISE
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State | ID
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Zip | 83709-1651
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Country | US
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Telephone | 208-378-4288
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Fax | 208-378-4297
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Provider Business Mailing Address
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Address Line | 227 SUNRISE RIM RD
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City | NAMPA
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State | ID
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Zip | 83686-8325
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Country | US
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Telephone | 208-912-3307
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 9871643
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License Number State | ID
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