Provider Demographics
NPI:1992215545
Name:KOLB, JASON E (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:E
Last Name:KOLB
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 1:3340 E GOLDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-3300
Mailing Address - Fax:208-302-3355
Practice Address - Street 1:1075 N CURTIS RD
Practice Address - Street 2:STE 201
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-302-3300
Practice Address - Fax:208-302-3355
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA202158363A00000X
IDPA-1545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant