Provider Demographics
NPI:1790923621
Name:FLYNN, CHRISTIE DUDASH (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:DUDASH
Last Name:FLYNN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DUDASH
Other - Middle Name:
Other - Last Name:DUDASH
Other - Suffix:
Other - Last Name Type:Former 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:208-367-6330
Mailing Address - Fax:208-367-4765
Practice Address - Street 1:12273 W MCMILLIAN ROAD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713
Practice Address - Country:US
Practice Address - Phone:208-367-6330
Practice Address - Fax:208-367-4765
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053777363AM0700X
IDPA-1029363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA150160NH3Medicare PIN