Provider Demographics
NPI:1336196757
Name:NIELSEN, KATHLEEN ROSE (PA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ROSE
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3041 E COPPER POINT DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1740
Mailing Address - Country:US
Mailing Address - Phone:208-514-4400
Mailing Address - Fax:208-514-4404
Practice Address - Street 1:3041 E COPPER POINT DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1740
Practice Address - Country:US
Practice Address - Phone:208-514-4400
Practice Address - Fax:208-514-4404
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA411363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA411OtherIDAHO MEDICAL LICENSE
IDMN0758493OtherDEA NUMBER
IDP51704Medicare UPIN