=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912035999
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL D HARDESTY PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 12/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1055 N CURTIS RD
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-1309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-367-8855
-----------------------------------------------------
Fax | 208-954-8073
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 190930
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83719-0930
-----------------------------------------------------
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 | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | C04084
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT-283
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA-903
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------