Provider Demographics
NPI:1700391620
Name:COX, KAITLIN L (PA)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:L
Last Name:COX
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 1:98 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1758
Mailing Address - Country:US
Mailing Address - Phone:208-232-6100
Mailing Address - Fax:208-785-8529
Practice Address - Street 1:777 HOSPITAL WAY STE 300
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5176
Practice Address - Country:US
Practice Address - Phone:208-232-6100
Practice Address - Fax:208-239-3403
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1683363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA-1683OtherID LICENSE
MAPA6337OtherMA LICENSE