Provider Demographics
NPI:1376090985
Name:WREN, STEPHEN MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:WREN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:STEPHEN
Other - Middle Name:MICHAEL
Other - Last Name:WREN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
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
Mailing Address - Country:US
Mailing Address - Phone:208-302-6600
Mailing Address - Fax:208-302-6655
Practice Address - Street 1:11035 W KARCHER RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651
Practice Address - Country:US
Practice Address - Phone:208-302-6600
Practice Address - Fax:208-302-6655
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1396363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant