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General NPI Number Information
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NPI Number | 1447966213
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Entity Type | Individual
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Provider Name | KELSY REID HACKER PA-C
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Gender | Female
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Dates
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Enumeration Date | 01/25/2023
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Last Update Date | 01/28/2025
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Provider Practice Location Address
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Address Line | 1072 N LIBERTY ST STE 201
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City | BOISE
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State | ID
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Zip | 83704-8708
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Country | US
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Telephone | 208-302-2400
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Fax | 208-302-2455
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Provider Business Mailing Address
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Address Line | 3340 E GOLDSTONE DR
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City | MERIDIAN
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State | ID
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Zip | 83642-1026
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Country | US
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Telephone | 208-367-5170
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Fax | 208-367-5180
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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-2449
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License Number State | ID
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