=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629814892
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AARON CLAYSON AG-NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2024
-----------------------------------------------------
Last Update Date | 08/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4511 ZEBE AVE
-----------------------------------------------------
City | CHUBBUCK
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83202-4707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-904-4780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4511 ZEBE AVE
-----------------------------------------------------
City | CHUBBUCK
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83202-4707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-904-4780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 2261477
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------