Provider Demographics
NPI:1407862139
Name:PICANCO, JAMES SR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:PICANCO
Suffix:SR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MISSION ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT HALL
Mailing Address - State:ID
Mailing Address - Zip Code:83203-0717
Mailing Address - Country:US
Mailing Address - Phone:208-238-5427
Mailing Address - Fax:
Practice Address - Street 1:MISSION ROAD
Practice Address - Street 2:
Practice Address - City:FORT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203-0717
Practice Address - Country:US
Practice Address - Phone:208-238-5427
Practice Address - Fax:208-238-5465
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01153363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP82927Medicare UPIN