Provider Demographics
NPI:1770822074
Name:BOCK, AMBER (PAC)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:BOCK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-302-9342
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:4424 E FLAMINGO AVE STE 300
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9306
Practice Address - Country:US
Practice Address - Phone:208-302-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA209074363A00000X
WYTL559363A00000X
IDPA-1169363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant