Provider Demographics
NPI:1033935093
Name:LISTER, KALIN DANIAL (STUDENT)
Entity type:Individual
Prefix:
First Name:KALIN
Middle Name:DANIAL
Last Name:LISTER
Suffix:
Gender:
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 SUNRISE RIM RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-8325
Mailing Address - Country:US
Mailing Address - Phone:208-912-3307
Mailing Address - Fax:
Practice Address - Street 1:8971 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1651
Practice Address - Country:US
Practice Address - Phone:208-378-4288
Practice Address - Fax:208-378-4297
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID9871643363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant