Provider Demographics
NPI:1689977019
Name:LETKO, KARL M (MPAS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:KARL
Middle Name:M
Last Name:LETKO
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 S 11TH AVE
Mailing Address - Street 2:SUITE 503
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4835
Mailing Address - Country:US
Mailing Address - Phone:208-239-1710
Mailing Address - Fax:208-239-1713
Practice Address - Street 1:500 S 11TH AVE
Practice Address - Street 2:SUITE 503
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4835
Practice Address - Country:US
Practice Address - Phone:208-239-1710
Practice Address - Fax:208-239-1713
Is Sole Proprietor?:No
Enumeration Date:2010-12-07
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21368363AM0700X
IDPA-916363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical