Provider Demographics
NPI:1780194613
Name:PIQUET, KOLT MONTE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KOLT
Middle Name:MONTE
Last Name:PIQUET
Suffix:
Gender:M
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 1:1675 CURLEW DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4850
Mailing Address - Country:US
Mailing Address - Phone:208-523-5319
Mailing Address - Fax:208-523-5627
Practice Address - Street 1:1675 CURLEW DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4850
Practice Address - Country:US
Practice Address - Phone:208-523-5319
Practice Address - Fax:208-523-5627
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant