Basic Information
Provider Information | |||||||||
NPI: | 1356747042 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BARNES | ||||||||
FirstName: | DANIELLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2315 8TH ST | ||||||||
Address2: |   | ||||||||
City: | LEWISTON | ||||||||
State: | ID | ||||||||
PostalCode: | 835017301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087461383 | ||||||||
FaxNumber: | 2087466348 | ||||||||
Practice Location | |||||||||
Address1: | 2315 8TH ST | ||||||||
Address2: |   | ||||||||
City: | LEWISTON | ||||||||
State: | ID | ||||||||
PostalCode: | 835017301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087461383 | ||||||||
FaxNumber: | 2087466348 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2014 | ||||||||
LastUpdateDate: | 02/16/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA60494489 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA-1210 | ID | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | PA60494489 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1356747042 | 05 | ID |   | MEDICAID | 1356747042 | 05 | WA |   | MEDICAID |