Provider Demographics
NPI:1497723217
Name:LANDLE, KELLY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:LANDLE
Suffix:
Gender:F
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 1:700 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3046
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:
Practice Address - Street 1:606 E MAIN ST
Practice Address - Street 2:
Practice Address - City:KENDRICK
Practice Address - State:ID
Practice Address - Zip Code:83537
Practice Address - Country:US
Practice Address - Phone:208-289-3841
Practice Address - Fax:208-289-3961
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-345363A00000X
WAPA10004069363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806673600Medicaid
970027265OtherRAILROAD MEDICARE
WA0141613OtherSTATE WORK COMP
WA8201634Medicaid
WA0141613OtherSTATE WORK COMP
WA8201634Medicaid
ID806673600Medicaid