Basic Information
| Provider Information | |||||||||
| NPI: | 1386063980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | COLIN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052863826 | ||||||||
| FaxNumber: | 8052216843 | ||||||||
| Practice Location | |||||||||
| Address1: | 13500 S. PLEASANT VALLEY | ||||||||
| Address2: | |||||||||
| City: | KUNA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089228312 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2014 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 51458 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA-1176 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.