Provider Demographics
NPI:1871753061
Name:KINGHORN, ELISABETH GAYLE (PA)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:GAYLE
Last Name:KINGHORN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N. 4TH AVE STE B
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-269-7147
Mailing Address - Fax:208-416-6522
Practice Address - Street 1:151 N. 4TH AVE STE B
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-269-7147
Practice Address - Fax:208-416-6522
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA-693OtherIDAHO LICENSE