Provider Demographics
NPI:1649643289
Name:PAYSON, STEVEN (ATC)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:PAYSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4275 S TRAILRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-6633
Mailing Address - Country:US
Mailing Address - Phone:208-761-5918
Mailing Address - Fax:
Practice Address - Street 1:650 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-3423
Practice Address - Country:US
Practice Address - Phone:541-881-5882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-5452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer