MEDICARE: LAURA POLY PA

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	363AM0700X	Medical Physician Assistant	PA-895	ID

General Provider Information

NPI Number	:	1386933513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA POLY PA

Provider Business Mailing Address
First Line	:	500 W FORT ST # 111
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83702-4599
Country	:	US
Telephone Number	:	208-422-1325
Fax Number	:	208-422-1319

Provider Business Practice Location Address
First Line	:	500 W FORT ST # 111
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83702-4599
Country	:	US
Telephone Number	:	208-422-1325
Fax Number	:	208-422-1319

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

Provider Enumeration Date	:	03/28/2011
Last Update Date	:	02/25/2022

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Directions to “ LAURA POLY PA” Practice Location

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