Provider Demographics
NPI:1851728133
Name:POWELL, KATHRYN LEA (MPAS)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LEA
Last Name:POWELL
Suffix:
Gender:F
Credentials:MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3277 E LOUISE DR
Mailing Address - Street 2:SUITE 410
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9359
Mailing Address - Country:US
Mailing Address - Phone:208-489-5800
Mailing Address - Fax:208-489-4065
Practice Address - Street 1:3277 E LOUISE DR
Practice Address - Street 2:SUITE 410
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9359
Practice Address - Country:US
Practice Address - Phone:208-489-5800
Practice Address - Fax:208-489-4065
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTLP-011363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant