Provider Demographics
NPI:1811975386
Name:HESSE, PHILIP C (PA)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:C
Last Name:HESSE
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:PO BOX 1647
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1647
Mailing Address - Country:US
Mailing Address - Phone:208-535-4130
Mailing Address - Fax:208-535-4125
Practice Address - Street 1:2377 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7440
Practice Address - Country:US
Practice Address - Phone:208-557-2570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA87363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPASPAOtherBLUE CHOICE
ID806633300Medicaid
ID1666210Medicare ID - Type Unspecified