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NPI Code Detail

MEDICARE: MR. LARRY MICHAEL OBORN PA-C

MEDICARE: MR. LARRY MICHAEL OBORN 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
1363LF0000XFamily Nurse PractitionerPA11201CA
2363AM0700XMedical Physician AssistantPA-1099ID

General Provider Information

NPI Number : 1942219233
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. LARRY MICHAEL OBORN PA-C
Provider Business Mailing Address
First Line : PO BOX 191050
Second Line :
City : BOISE
State : ID
Zip : 83719-1050
Country : US
Telephone Number : 208-955-6522
Fax Number : 208-955-6503
Provider Business Practice Location Address
First Line : 11197 W FAIRVIEW AVE
Second Line :
City : BOISE
State : ID
Zip : 83713-7935
Country : US
Telephone Number : 208-378-8011
Fax Number : 208-322-8095
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/05/2006
Last Update Date : 07/08/2014

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