Provider Demographics
NPI:1265800742
Name:GIFFORD, LAURA MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MARIE
Last Name:GIFFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:MARIE
Other - Last Name:HILDEBRANDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:415 6TH STREET
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2431
Mailing Address - Country:US
Mailing Address - Phone:208-799-5457
Mailing Address - Fax:208-799-5766
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:208-743-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61022472363A00000X
IDPA-1434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2074831Medicaid