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General NPI Number Information
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NPI Number | 1174148696
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Entity Type | Individual
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Provider Name | COLTON JASON RANDALL PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/10/2020
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Last Update Date | 02/09/2026
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Provider Practice Location Address
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Address Line | 775 POLE LINE RD W STE 112
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City | TWIN FALLS
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State | ID
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Zip | 83301-5819
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Country | US
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Telephone | 208-814-8200
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Fax | 208-933-4921
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Provider Business Mailing Address
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Address Line | 190 E BANNOCK ST
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City | BOISE
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State | ID
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Zip | 83712-6241
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Country | US
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Telephone |
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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 | PA-1928
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License Number State | ID
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