Provider Demographics
NPI:1447227293
Name:LANDES, TROY A (PA)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:A
Last Name:LANDES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 16TH AVE N
Mailing Address - Street 2:PO BOX 9
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-4058
Mailing Address - Country:US
Mailing Address - Phone:208-461-7149
Mailing Address - Fax:208-467-3391
Practice Address - Street 1:201 MAIN
Practice Address - Street 2:
Practice Address - City:MARSING
Practice Address - State:ID
Practice Address - Zip Code:83639
Practice Address - Country:US
Practice Address - Phone:208-896-4159
Practice Address - Fax:208-896-4917
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA050718363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA25-1716306OtherINTERGROUP
PA50064072OtherCAPITAL BLUECROSS
PA120420414OtherDEPT OF LABOR
PA25-1716306OtherINFORMED
PA498815OtherHEALTH AMERICA
PA1007307260034OtherMEDICARE GROUP #
PAMA050718OtherLICENSE
PA25-1716306OtherSOUTH CENTRAL PREFERRED
PAML0765567OtherDEA
PA50064072OtherCAPITAL BLUECROSS
PAML0765567OtherDEA