Provider Demographics
NPI:1538121322
Name:TABOR, LAURA A (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:TABOR
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 1:1880 JOHN ADAMS PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4315
Mailing Address - Country:US
Mailing Address - Phone:208-524-6633
Mailing Address - Fax:208-524-9952
Practice Address - Street 1:1880 JOHN ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4315
Practice Address - Country:US
Practice Address - Phone:208-524-6633
Practice Address - Fax:208-524-9952
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA415363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPAC63OtherBLUE CROSS PROVIDER NUMBE
ID807659300Medicaid
ID8K123OtherBLUE CROSS GROUP
IDP00205234OtherRAILROAD MEDICARE NUMBER
ID1134140148OtherBAKER FAMILY GROUP NPI
ID000010027582OtherREGENCE BLUESHIELD GROUP
IDDE1614OtherRAILROAD MCR GROUP
ID000010156316OtherREGENCE BLUE SHIELD
ID806887600Medicaid
IDP80646Medicare UPIN
IDP00205234OtherRAILROAD MEDICARE NUMBER
ID8K123OtherBLUE CROSS GROUP