MEDICARE: KORDELL ALAN KOEPNICK 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	363A00000X	Physician Assistant	PA6140460	WA
2	363A00000X	Physician Assistant	PA219548	OR
3	363A00000X	Physician Assistant	PA-2450	ID

General Provider Information

NPI Number	:	1770289621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KORDELL ALAN KOEPNICK PA

Provider Business Mailing Address
First Line	:	11504 PAINTBRUSH LN
Second Line	:
City	:	POCATELLO
State	:	ID
Zip	:	83202-5077
Country	:	US
Telephone Number	:	208-312-7630
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 S 8TH ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83702-7107
Country	:	US
Telephone Number	:	855-255-1750
Fax Number	:	855-255-0905

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

Provider Enumeration Date	:	02/02/2023
Last Update Date	:	09/27/2024

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Directions to “ KORDELL ALAN KOEPNICK PA” Practice Location

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