Provider Demographics
NPI:1639642051
Name:KRAUSE, KELLY (PA-S)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KRAUSE
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:6565 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8737
Practice Address - Country:US
Practice Address - Phone:208-514-2510
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPAT-1634363A00000X
IDPA-2022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1639642051Medicaid