Provider Demographics
NPI:1588011928
Name:CARDONA, ALICIA JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:JEAN
Last Name:CARDONA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:JEAN
Other - Last Name:TIGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:267 N CANYON DR
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-5500
Mailing Address - Country:US
Mailing Address - Phone:208-934-4446
Mailing Address - Fax:208-934-4442
Practice Address - Street 1:267 N CANYON DR
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-5500
Practice Address - Country:US
Practice Address - Phone:208-934-4446
Practice Address - Fax:208-934-4442
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1516363A00000X
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program