Provider Demographics
NPI:1821183617
Name:HAMILTON, KENT LEROY (PAC)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:LEROY
Last Name:HAMILTON
Suffix:
Gender:M
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 871
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-0871
Mailing Address - Country:US
Mailing Address - Phone:208-549-0211
Mailing Address - Fax:208-549-0104
Practice Address - Street 1:683 E 3RD ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2248
Practice Address - Country:US
Practice Address - Phone:208-549-0211
Practice Address - Fax:208-549-0104
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPA-149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004369700Medicaid
ID004369700Medicaid
ID010051831Medicare PIN
IDC60019Medicare UPIN