Provider Demographics
NPI:1558951764
Name:MONDADA, CARSON NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:NICOLE
Last Name:MONDADA
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 1:3301 N SAWGRASS WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4493
Mailing Address - Country:US
Mailing Address - Phone:208-375-0862
Mailing Address - Fax:
Practice Address - Street 1:3301 N SAWGRASS WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4493
Practice Address - Country:US
Practice Address - Phone:208-375-0862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical