Provider Demographics
NPI:1245741503
Name:EICHENLAUB, ALISON CARROLL (PA-C)
Entity Type:Individual
Prefix:
First Name:ALISON
Middle Name:CARROLL
Last Name:EICHENLAUB
Suffix:
Gender:F
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 1:3652 S PHEASANT TAIL WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-5087
Mailing Address - Country:US
Mailing Address - Phone:540-421-1222
Mailing Address - Fax:
Practice Address - Street 1:10583 W LAKE HAZEL RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-6326
Practice Address - Country:US
Practice Address - Phone:208-302-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1544363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical