Provider Demographics
NPI:1386192102
Name:VERNON, MONICA (PA)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:VERNON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 NW 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2265
Mailing Address - Country:US
Mailing Address - Phone:208-302-6600
Mailing Address - Fax:208-302-6655
Practice Address - Street 1:11035 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:2016-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant