MEDICARE: LAURA IVIE 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
2	363A00000X	Physician Assistant		ID
3	363A00000X	Physician Assistant	PA-938	ID

General Provider Information

NPI Number	:	1205135456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA IVIE PA-C

Provider Business Mailing Address
First Line	:	3360 WASHINGTON PKWY STE 1
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-8333
Country	:	US
Telephone Number	:	208-524-3416
Fax Number	:

Provider Business Practice Location Address
First Line	:	3360 WASHINGTON PKWY STE 1
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-8333
Country	:	US
Telephone Number	:	208-524-3416
Fax Number	:	208-524-3138

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

Provider Enumeration Date	:	03/26/2011
Last Update Date	:	03/08/2022

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Directions to “ LAURA IVIE PA-C” Practice Location

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