Provider Demographics
NPI:1083646301
Name:SIJAN, TOD ALAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TOD
Middle Name:ALAN
Last Name:SIJAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8836 N HESS ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8718
Mailing Address - Country:US
Mailing Address - Phone:208-762-7760
Mailing Address - Fax:208-762-7740
Practice Address - Street 1:8836 N HESS ST
Practice Address - Street 2:SUITE C
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8718
Practice Address - Country:US
Practice Address - Phone:208-762-7760
Practice Address - Fax:208-762-7740
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15406363AM0700X
IDPA-1237363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP10624Medicare UPIN