Provider Demographics
NPI:1588227656
Name:PERMENTER, TRACI H (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:H
Last Name:PERMENTER
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:PO BOX 16303
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83715-6303
Mailing Address - Country:US
Mailing Address - Phone:713-858-1040
Mailing Address - Fax:
Practice Address - Street 1:303 N ALLUMBAUGH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9208
Practice Address - Country:US
Practice Address - Phone:208-888-5848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1717363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant