1104044247 NPI number — DAVID M LANDIS PA-C

Table of content: DAVID M LANDIS PA-C (NPI 1104044247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104044247 NPI number — DAVID M LANDIS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANDIS
Provider First Name:
DAVID
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104044247
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 E BANNOCK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83712-6241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-381-2222
Provider Business Mailing Address Fax Number:
208-426-4634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
703 S AMERICANA BLVD
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702-5099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-706-7500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA165 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RPA-165 . This is a "LICENSE NO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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