Provider Demographics
NPI:1043665789
Name:HOUSLEY, MICHAEL J (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:HOUSLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7733 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9020
Mailing Address - Country:US
Mailing Address - Phone:208-376-3220
Mailing Address - Fax:208-939-5010
Practice Address - Street 1:7733 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9020
Practice Address - Country:US
Practice Address - Phone:208-376-3220
Practice Address - Fax:208-939-5010
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1448363A00000X
TXPA08766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant