Provider Demographics
NPI:1114966959
Name:FRELLY, STEPHEN J (PA)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:J
Last Name:FRELLY
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:1618 S MILLENIUM WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6457
Mailing Address - Country:US
Mailing Address - Phone:208-884-3376
Mailing Address - Fax:208-884-0858
Practice Address - Street 1:1618 S MILLENIUM WAY STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6457
Practice Address - Country:US
Practice Address - Phone:208-884-3376
Practice Address - Fax:208-884-0858
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2019-08-29
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Provider Licenses
StateLicense IDTaxonomies
IDPA495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant