Provider Demographics
NPI:1578716072
Name:WILLARDSON, JED BURKE (PA)
Entity Type:Individual
Prefix:
First Name:JED
Middle Name:BURKE
Last Name:WILLARDSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2404
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2404
Mailing Address - Country:US
Mailing Address - Phone:208-523-7246
Mailing Address - Fax:208-523-7247
Practice Address - Street 1:2377 CORONADO ST
Practice Address - Street 2:SUITE C
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7440
Practice Address - Country:US
Practice Address - Phone:208-523-7246
Practice Address - Fax:208-523-7247
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2009-03-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-779363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant