Provider Demographics
NPI:1083704498
Name:BROWN, MINDY L (PA)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:L
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:L
Other - Last Name:NELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:801 POLE LINE RD W
Practice Address - Street 2:SUITE 3810
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5810
Practice Address - Country:US
Practice Address - Phone:208-814-8500
Practice Address - Fax:208-734-4143
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-633363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807587700Medicaid
IDQ75081Medicare UPIN
ID16680211Medicare PIN