Provider Demographics
NPI:1376914838
Name:ROSKELLEY, MORGAN GRACE (PA-C)
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:GRACE
Last Name:ROSKELLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MORGAN
Other - Middle Name:GRACE
Other - Last Name:PRINGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:703 S. AMERICANA BLVD
Mailing Address - Street 2:STE 120
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-706-2663
Mailing Address - Fax:
Practice Address - Street 1:1034 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3380
Practice Address - Country:US
Practice Address - Phone:530-320-0298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11791838-1206363A00000X
IDPA-1311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant