Provider Demographics
NPI:1700447141
Name:NICHOLS, KATIE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ELIZABETH
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:4400 E FLAMINGO AVE STE 200
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9203
Practice Address - Country:US
Practice Address - Phone:208-302-2700
Practice Address - Fax:208-367-2725
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
FLPA9112309363AS0400X
IDPA-1889363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103724800Medicaid