Provider Demographics
NPI:1447449640
Name:GEOFFREY N SWANSON MD PA
Entity type:Organization
Organization Name:GEOFFREY N SWANSON MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:N
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:208-288-2255
Mailing Address - Street 1:2321 E GALA ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6351
Mailing Address - Country:US
Mailing Address - Phone:208-288-2255
Mailing Address - Fax:208-288-1535
Practice Address - Street 1:2321 E GALA ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7692
Practice Address - Country:US
Practice Address - Phone:208-288-2255
Practice Address - Fax:208-288-1535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6536363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty