Provider Demographics
NPI:1780928580
Name:SHORT, WILLIAM JOSEPH (PAC)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOSEPH
Last Name:SHORT
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 1:1775 W STATE ST # 383
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-3924
Mailing Address - Country:US
Mailing Address - Phone:208-912-4416
Mailing Address - Fax:208-549-5832
Practice Address - Street 1:1019 W SANETTA ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-5047
Practice Address - Country:US
Practice Address - Phone:208-917-1842
Practice Address - Fax:208-549-7017
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA160595363A00000X
IDPA1027363A00000X, 363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical