=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558445932
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLE ROBSON P.A.-C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 11/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 MADISON PROFESSIONAL PARK
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-2058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 82-656-9467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 MADISON PROFESSIONAL PARK
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-2058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 82-656-9467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA-310
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------