Basic Information
| Provider Information | |||||||||
| NPI: | 1417581869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROWL | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GORDON | ||||||||
| OtherFirstName: | ANNE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 777 N RAYMOND ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837049251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085142500 | ||||||||
| FaxNumber: | 2083752217 | ||||||||
| Practice Location | |||||||||
| Address1: | 2275 S EAGLE RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085142520 | ||||||||
| FaxNumber: | 2083752217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2020 | ||||||||
| LastUpdateDate: | 02/19/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA-1857 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA-1857 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.