Provider Demographics
NPI:1861121436
Name:SMITH, JOHN ERVIN (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ERVIN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6500
Mailing Address - Fax:208-955-6501
Practice Address - Street 1:700 CALDWELL BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1707
Practice Address - Country:US
Practice Address - Phone:208-809-2892
Practice Address - Fax:208-809-2893
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID3361575OtherPHYSICIANS ASSISTANT LICENSE