Basic Information
| Provider Information | |||||||||
| NPI: | 1184667164 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | LEA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 209 FOREST ST | ||||||||
| Address2: | |||||||||
| City: | MCCALL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836385256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086341776 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2008-0013 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA-1144 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.