Basic Information
| Provider Information | |||||||||
| NPI: | 1265441547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANNING | ||||||||
| FirstName: | NICOLE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 CALL CREEK DR | ||||||||
| Address2: | STE 7 | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832013072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082332032 | ||||||||
| FaxNumber: | 2082332175 | ||||||||
| Practice Location | |||||||||
| Address1: | 475 YELLOWSTONE AVE | ||||||||
| Address2: | STE E | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082320021 | ||||||||
| FaxNumber: | 2082320031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 06/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA-307 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PAIA0 | 01 | ID | BLUE CROSS OF ID PROV # | OTHER | 805791900 | 05 | ID | MEDICAID | 000010033582 | 01 | ID | REGENCE BS OF IDAHO PROV | OTHER |