Provider Demographics
NPI:1801132980
Name:VAN LIER, KATIE ELIZABETH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:ELIZABETH
Last Name:VAN LIER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KATIE
Other - Middle Name:E
Other - Last Name:GIBBONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3340 E GOLDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:10255 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1430
Practice Address - Country:US
Practice Address - Phone:208-302-5600
Practice Address - Fax:208-302-5655
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-18
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08089363A00000X
IDPA-2034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX317654YVLHMedicare PIN