Provider Demographics
NPI:1356075030
Name:MCUNE, ALEXANDRIA RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:RENEE
Last Name:MCUNE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALEXANDRIA
Other - Middle Name:RENEE
Other - Last Name:VAN HALDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1210 NW 16TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2202
Practice Address - Country:US
Practice Address - Phone:208-452-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2365363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program