Provider Demographics
NPI:1225412943
Name:O'CONNOR, JARED GALBRAITH (PA-C)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:GALBRAITH
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-6330
Mailing Address - Fax:208-367-4765
Practice Address - Street 1:12273 W MCMILLAN ROAD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713
Practice Address - Country:US
Practice Address - Phone:208-367-6330
Practice Address - Fax:208-367-4765
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-1323363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant