Provider Demographics
NPI:1134376130
Name:PEWE, JEFFREY A (PA)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:PEWE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 S FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1306
Mailing Address - Country:US
Mailing Address - Phone:208-327-0066
Mailing Address - Fax:208-378-9864
Practice Address - Street 1:1305 S FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1306
Practice Address - Country:US
Practice Address - Phone:208-327-0066
Practice Address - Fax:208-378-9864
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-489111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1689696650OtherMEDICARE GROUP NPI