Provider Demographics
NPI:1417066143
Name:GUNDERSON, CHRISTOPHER D (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:D
Last Name:GUNDERSON
Suffix:
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:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6500
Mailing Address - Fax:
Practice Address - Street 1:5601 W CHINDEN BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:ID
Practice Address - Zip Code:83714-1463
Practice Address - Country:US
Practice Address - Phone:208-809-2865
Practice Address - Fax:208-809-2866
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-742363A00000X
WAPA10004402363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP74232Medicare UPIN
ID1665119Medicare PIN