Provider Demographics
NPI:1710282074
Name:FOSSEN, KATHLEEN LEIGH (PA)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:LEIGH
Last Name:FOSSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LEIGH
Other - Last Name:FOSSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
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:208-367-3330
Mailing Address - Fax:208-367-3331
Practice Address - Street 1:1075 N CURTIS ROAD
Practice Address - Street 2:STE 300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1309
Practice Address - Country:US
Practice Address - Phone:208-367-3330
Practice Address - Fax:208-367-3331
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AS0400X, 363AM0700X
IDPA-1165363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical