Provider Demographics
NPI:1881050540
Name:ANDERSON, NOEL (PA-C)
Entity type:Individual
Prefix:
First Name:NOEL
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
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 1:425 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6035
Mailing Address - Country:US
Mailing Address - Phone:208-343-6458
Mailing Address - Fax:
Practice Address - Street 1:425 W BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6035
Practice Address - Country:US
Practice Address - Phone:208-343-6458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA 9109214363A00000X
IDPA1897363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant