Provider Demographics
NPI:1629228978
Name:SIERRA, TALIA M (PA)
Entity Type:Individual
Prefix:
First Name:TALIA
Middle Name:M
Last Name:SIERRA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TALIA
Other - Middle Name:MARIE
Other - Last Name:FROST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-286-6676
Mailing Address - Fax:208-947-3419
Practice Address - Street 1:3217 W BAVARIA STREET
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-286-6676
Practice Address - Fax:208-947-3419
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-768363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA-768OtherIDAHO BOARD OF MEDICINE
ID1629228978Medicaid