Basic Information
| Provider Information | |||||||||
| NPI: | 1821484452 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | LOUISSA | ||||||||
| MiddleName: | CAROLYN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SAUTER | ||||||||
| OtherFirstName: | LOUISSA | ||||||||
| OtherMiddleName: | C | ||||||||
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| OtherCredential: | |||||||||
| 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: | 121 E FORT ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085142525 | ||||||||
| FaxNumber: | 2083752217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60549072 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA-1772 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.