Basic Information
Provider Information | |||||||||
NPI: | 1518141563 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VIETH | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KNOLL | ||||||||
OtherFirstName: | PATRICIA | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1593 E POLSTON AVE | ||||||||
Address2: |   | ||||||||
City: | POST FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 838545326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082622300 | ||||||||
FaxNumber: | 2082622390 | ||||||||
Practice Location | |||||||||
Address1: | 1641 E POLSTON AVE STE 101 | ||||||||
Address2: |   | ||||||||
City: | POST FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 838547852 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2084574208 | ||||||||
FaxNumber: | 2084574197 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2007 | ||||||||
LastUpdateDate: | 01/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA-725 | ID | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA60944866 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA-725 | ID | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | PA725 | ID | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X | PA-725 | ID | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA60944866 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X | PA60944866 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.