Basic Information
| Provider Information | |||||||||
| NPI: | 1518934181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIENIASZ | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 726 | ||||||||
| Address2: | |||||||||
| City: | LAVA HOT SPRINGS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832460726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098604186 | ||||||||
| FaxNumber: | 5096826131 | ||||||||
| Practice Location | |||||||||
| Address1: | 845 W CENTER ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832044237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082327862 | ||||||||
| FaxNumber: | 2082327869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 05/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA10001740 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA 889 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1518934181 | 05 | ID | MEDICAID | 1032150 | 05 | WA | MEDICAID |