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General NPI Number Information
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NPI Number | 1326855347
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Entity Type | Individual
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Provider Name | STEFEN JULE PICTON PTA
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Gender | Male
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Dates
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Enumeration Date | 12/12/2024
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Last Update Date | 12/12/2024
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Provider Practice Location Address
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Address Line | 5520 N EAGLE RD STE 102
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City | BOISE
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State | ID
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Zip | 83713-2703
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Country | US
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Telephone | 208-938-5255
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Fax |
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Provider Business Mailing Address
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Address Line | 2095 S ATLANTIC ST
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City | BOISE
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State | ID
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Zip | 83705-3208
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Country | US
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Telephone | 828-263-3324
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 9671436
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License Number State | ID
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