Provider Demographics
NPI:1356346712
Name:LOUNSBURY, MICHAEL (PAC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:LOUNSBURY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 N LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3243
Mailing Address - Country:US
Mailing Address - Phone:208-827-6127
Mailing Address - Fax:
Practice Address - Street 1:318 N LINCOLN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3243
Practice Address - Country:US
Practice Address - Phone:208-827-6127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002373363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDS77447Medicare UPIN
ID805232400Medicaid
ID1665931Medicare UPIN