Provider Demographics
NPI:1558713131
Name:FOSTER, JACOB R (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:FOSTER
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 1:110 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5824
Mailing Address - Country:US
Mailing Address - Phone:208-234-2300
Mailing Address - Fax:208-234-0026
Practice Address - Street 1:110 VISTA DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5824
Practice Address - Country:US
Practice Address - Phone:208-234-2300
Practice Address - Fax:208-234-0026
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant