Provider Demographics
NPI:1710088208
Name:LINDBERG, GWEN AILEEN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:GWEN
Middle Name:AILEEN
Last Name:LINDBERG
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 1:500 W FORT ST
Mailing Address - Street 2:# 111
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4501
Mailing Address - Country:US
Mailing Address - Phone:208-422-1000
Mailing Address - Fax:208-422-1053
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:# 111
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:208-422-1053
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPA-164363A00000X
IDPA-1060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant