Provider Demographics
NPI:1083739049
Name:LAIBLE, KATHERINE M (PAC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:M
Last Name:LAIBLE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6040
Mailing Address - Country:US
Mailing Address - Phone:208-888-2080
Mailing Address - Fax:208-888-4296
Practice Address - Street 1:311 W IDAHO ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6040
Practice Address - Country:US
Practice Address - Phone:208-888-2080
Practice Address - Fax:208-888-4296
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant