Provider Demographics
NPI:1811002900
Name:OZIER, MARYANN (PA)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:OZIER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 W FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5121
Mailing Address - Country:US
Mailing Address - Phone:208-957-7400
Mailing Address - Fax:877-287-3117
Practice Address - Street 1:1702 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5121
Practice Address - Country:US
Practice Address - Phone:208-957-7400
Practice Address - Fax:877-287-3117
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-282363A00000X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1811002900Medicaid
ID805998300Medicaid
IDPAP59OtherBLUE CROSS OF IDAHO
4036070002Medicare NSC
P00415977Medicare PIN
ID1666640Medicare PIN
ID10178669OtherBLUE SHIELD