Provider Demographics
NPI:1588616122
Name:HURTY, MICHELLE R (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:HURTY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E JEFFERSON ST
Mailing Address - Street 2:STE 201
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6246
Mailing Address - Country:US
Mailing Address - Phone:208-381-4100
Mailing Address - Fax:208-381-1665
Practice Address - Street 1:300 E JEFFERSON ST
Practice Address - Street 2:STE 201
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6246
Practice Address - Country:US
Practice Address - Phone:208-381-4100
Practice Address - Fax:208-381-1665
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA186363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S99495Medicare UPIN
1666537Medicare ID - Type Unspecified