Provider Demographics
NPI:1811926421
Name:PURSLOW, MICHAEL TOBIN (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TOBIN
Last Name:PURSLOW
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:928-526-0751
Mailing Address - Fax:
Practice Address - Street 1:200 FOREST ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-5256
Practice Address - Country:US
Practice Address - Phone:208-630-2470
Practice Address - Fax:208-630-2475
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3192363A00000X
IDPA-1773363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS52911Medicare UPIN
AZ103954Medicare ID - Type Unspecified