Provider Demographics
NPI:1164777181
Name:KILLPACK, JOSHUA D (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:D
Last Name:KILLPACK
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 1:2325 CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7407
Mailing Address - Country:US
Mailing Address - Phone:208-557-2700
Mailing Address - Fax:
Practice Address - Street 1:2442 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7549
Practice Address - Country:US
Practice Address - Phone:208-552-4909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-985363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant