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
StateLicense IDTaxonomies
CAPA11201363LF0000X
IDPA-1099363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA942492609OtherTAX ID NUMBER