MEDICARE: COLTON JASON RANDALL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA-1928	ID

General Provider Information

NPI Number	:	1174148696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLTON JASON RANDALL PA-C

Provider Business Mailing Address
First Line	:	190 E BANNOCK ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83712-6241
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	775 POLE LINE RD W STE 112
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-5819
Country	:	US
Telephone Number	:	208-814-8200
Fax Number	:	208-933-4921

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2020
Last Update Date	:	02/09/2026

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Directions to “ COLTON JASON RANDALL PA-C” Practice Location

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