Provider Demographics
NPI: | 1942219233 |
---|---|
Name: | OBORN, LARRY MICHAEL (PA-C) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | LARRY |
Middle Name: | MICHAEL |
Last Name: | OBORN |
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: | PO BOX 191050 |
Mailing Address - Street 2: | |
Mailing Address - City: | BOISE |
Mailing Address - State: | ID |
Mailing Address - Zip Code: | 83719-1050 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 208-955-6522 |
Mailing Address - Fax: | 208-955-6503 |
Practice Address - Street 1: | 11197 W FAIRVIEW AVE |
Practice Address - Street 2: | |
Practice Address - City: | BOISE |
Practice Address - State: | ID |
Practice Address - Zip Code: | 83713-7935 |
Practice Address - Country: | US |
Practice Address - Phone: | 208-378-8011 |
Practice Address - Fax: | 208-322-8095 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-05 |
Last Update Date: | 2014-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | PA11201 | 363LF0000X |
ID | PA-1099 | 363AM0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 942492609 | Other | TAX ID NUMBER |