MEDICARE: ADA WEST DERMATOPATHOLOGY, LLC

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	291U00000X	Clinical Medical Laboratory	P1629	ID

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20002043	OTHER	ID	MEDICARE PTAN

General Provider Information

NPI Number	:	1760730436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADA WEST DERMATOPATHOLOGY, LLC

Provider Business Mailing Address
First Line	:	1618 MILLENIUM WAY
Second Line	:	STE 220
City	:	MERIDIAN
State	:	ID
Zip	:	83642-6439
Country	:	US
Telephone Number	:	208-884-3376
Fax Number	:	208-884-0858

Provider Business Practice Location Address
First Line	:	1618 MILLENIUM WAY
Second Line	:	STE 220
City	:	MERIDIAN
State	:	ID
Zip	:	83642-6439
Country	:	US
Telephone Number	:	208-884-3376
Fax Number	:	208-884-0858

Authorized Official
Title or Position	:	CFO
Name	:	COLLEEN JONES
Credential	:
Telephone Number	:	208-884-3376

Provider Enumeration Date	:	08/28/2012
Last Update Date	:	05/18/2026

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