Provider Demographics
NPI:1609341098
Name:TAYSOM, ARIEL SHANTAY AVIS (PA-C)
Entity Type:Individual
Prefix:
First Name:ARIEL
Middle Name:SHANTAY AVIS
Last Name:TAYSOM
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 1:220 BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-5068
Mailing Address - Country:US
Mailing Address - Phone:208-766-2600
Mailing Address - Fax:208-766-4258
Practice Address - Street 1:220 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-5068
Practice Address - Country:US
Practice Address - Phone:208-766-2600
Practice Address - Fax:208-766-4258
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1656363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant