=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841875895
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA ANNE BARCELO PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2021
-----------------------------------------------------
Last Update Date | 06/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 W 1ST S
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-1810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-356-8883
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 636 N 2743 E
-----------------------------------------------------
City | ROBERTS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83444-5068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | PA-2037
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA-2037
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------