Provider Demographics
NPI:1851658595
Name:ANDERSEN, DALLIN (PA-C)
Entity Type:Individual
Prefix:
First Name:DALLIN
Middle Name:
Last Name:ANDERSEN
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 1:1494 W. USTICK RD.
Mailing Address - Street 2:110
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646
Mailing Address - Country:US
Mailing Address - Phone:208-954-0101
Mailing Address - Fax:208-908-6588
Practice Address - Street 1:1494 W. USTICK RD.
Practice Address - Street 2:110
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646
Practice Address - Country:US
Practice Address - Phone:208-908-7797
Practice Address - Fax:208-908-6588
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant