Basic Information
| Provider Information | |||||||||
| NPI: | 1558838136 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WINWARD | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | THANE | ||||||||
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| Credential: | PA-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: | 2550 ADDISON AVE E | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833016767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088148000 | ||||||||
| FaxNumber: | 2089339301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2018 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA0423 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.