Basic Information
| Provider Information | |||||||||
| NPI: | 1003546276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESTENDORF | ||||||||
| FirstName: | MALINDA | ||||||||
| MiddleName: | PAIGE | ||||||||
| NamePrefix: | MS. | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | WESTENDORF | ||||||||
| OtherFirstName: | LINDY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083818866 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 465 MCKENNA DR | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836472143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085879703 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2022 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA-2379 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.