Basic Information
| Provider Information | |||||||||
| NPI: | 1902340987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANCE | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | MALLOY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24547 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981240547 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 2ND AVE N | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833016158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007690045 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2016 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 54086 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 1504 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.