Provider Demographics
NPI:1801862784
Name:KIRKPATRICK, NORA L (PA)
Entity type:Individual
Prefix:
First Name:NORA
Middle Name:L
Last Name:KIRKPATRICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NORA
Other - Middle Name:L
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4511 ZEBE AVE
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4707
Mailing Address - Country:US
Mailing Address - Phone:208-904-4780
Mailing Address - Fax:208-904-4832
Practice Address - Street 1:4511 ZEBE AVE
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-4707
Practice Address - Country:US
Practice Address - Phone:208-904-4780
Practice Address - Fax:208-904-4832
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-29277363A00000X
OK1852363A00000X
VA0110004220363A00000X
IDPA-1754363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200271010AMedicaid
KS200271010AMedicaid
KS200271010AMedicaid