Basic Information
| Provider Information | |||||||||
| NPI: | 1497723217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDLE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838433046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088824511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 606 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | KENDRICK | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082893841 | ||||||||
| FaxNumber: | 2082893961 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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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 | 363A00000X | PA-345 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA10004069 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | PA10004069 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 806673600 | 05 | ID | MEDICAID | 970027265 | 01 | RAILROAD MEDICARE | OTHER | 0141613 | 01 | WA | STATE WORK COMP | OTHER | 8201634 | 05 | WA | MEDICAID |