Provider Demographics
NPI:1265820229
Name:YAN, JIE (PA)
Entity Type:Individual
Prefix:
First Name:JIE
Middle Name:
Last Name:YAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:YAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
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:208-367-7393
Practice Address - Street 1:12273 W MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0555
Practice Address - Country:US
Practice Address - Phone:208-367-6330
Practice Address - Fax:208-367-7393
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-29
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1218363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant