Provider Demographics
NPI:1952402257
Name:POOL, JUSTIN C (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:C
Last Name:POOL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2600
Mailing Address - Country:US
Mailing Address - Phone:208-233-2100
Mailing Address - Fax:208-233-3146
Practice Address - Street 1:2240 E CENTER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2600
Practice Address - Country:US
Practice Address - Phone:208-233-2100
Practice Address - Fax:208-233-3146
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5124950-1206363AM0700X
IDPA1007363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20001734Medicare PIN
ID20001735Medicare PIN
UTQ73294Medicare UPIN
ID20001733Medicare PIN