Provider Demographics
NPI:1962467977
Name:BURGESON, LAURA K (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:K
Last Name:BURGESON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:K
Other - Last Name:TRIPHAHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1986 W HAYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-7412
Mailing Address - Country:US
Mailing Address - Phone:208-762-7760
Mailing Address - Fax:208-762-7740
Practice Address - Street 1:1986 W HAYDEN AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-7412
Practice Address - Country:US
Practice Address - Phone:208-762-7760
Practice Address - Fax:208-762-7740
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA533363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807116700Medicaid
WA8421174Medicaid
16666921OtherMEDICARE PTAN
WA7144785Medicaid
ID8080036Medicaid
1370136OtherMEDICARE GROUP PTAN
16666921OtherMEDICARE PTAN