=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801132980
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATIE ELIZABETH VAN LIER PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2012
-----------------------------------------------------
Last Update Date | 05/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10255 W OVERLAND RD
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83709-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-302-5600
-----------------------------------------------------
Fax | 208-302-5655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3340 E GOLDSTONE DR
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-1026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-367-5170
-----------------------------------------------------
Fax | 208-367-5180
-----------------------------------------------------
=====================================================
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 | PA08089
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA-2034
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------