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General NPI Number Information
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NPI Number | 1225389414
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Entity Type | Organization
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Legal Business Name | IDAHO SURGICAL ASSISTANTS PLLC
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Dates
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Enumeration Date | 09/27/2012
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Last Update Date | 09/27/2012
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Provider Practice Location 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 | 208-381-2185
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Fax |
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Provider Business Mailing Address
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Address Line | 1601 E 17TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6313
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Country | US
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Telephone | 208-525-2090
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Fax | 208-523-8978
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Authorized Official
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Title or Position | BILLING SPECIALIST
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Name | REANNA PARK
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Credential |
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Telephone | 208-525-2090
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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-325
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License Number State | ID
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