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NPI Code Detail

MEDICARE: DONALD E SANFORD JR. PA

MEDICARE: DONALD E SANFORD JR. 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
1363A00000XPhysician AssistantPA-1779ID

General Provider Information

NPI Number : 1710537964
Entity Type Code : Individual
Provider Name (Legal Business Name) : DONALD E SANFORD JR. PA
Provider Business Mailing Address
First Line : PO BOX 191050
Second Line :
City : BOISE
State : ID
Zip : 83719-1050
Country : US
Telephone Number : 208-955-6500
Fax Number :
Provider Business Practice Location Address
First Line : 4815 CLEVELAND BLVD
Second Line :
City : CALDWELL
State : ID
Zip : 83605-6501
Country : US
Telephone Number : 208-455-3545
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/18/2019
Last Update Date : 09/18/2019

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Directions to “ DONALD E SANFORD JR. PA” Practice Location

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