Provider Demographics
NPI:1912073370
Name:PAYTASH, SUSAN E (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:PAYTASH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
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 1:1673 W SHORELINE DR
Practice Address - Street 2:SUITE 120
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6749
Practice Address - Country:US
Practice Address - Phone:208-367-8383
Practice Address - Fax:208-429-8310
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA596363AM0700X
IDPA-596363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807392700Medicaid
IDQ66145Medicare UPIN
ID1667581Medicare ID - Type Unspecified