Provider Demographics
NPI:1306826862
Name:WARNER, RITA LYNN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:LYNN
Last Name:WARNER
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:RITA
Other - Middle Name:LYNN
Other - Last Name:ROTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:265 W. PRAIRIE SHOPPING CENTER
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835
Mailing Address - Country:US
Mailing Address - Phone:208-772-7850
Mailing Address - Fax:208-772-2313
Practice Address - Street 1:265 W. PRAIRIE SHOPPING CENTER
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835
Practice Address - Country:US
Practice Address - Phone:208-772-7850
Practice Address - Fax:208-772-2313
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004688363A00000X
IDPAG-019363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAQ65241Medicare UPIN