Provider Demographics
NPI:1174096606
Name:AHLSTROM, DEREK SCOTT (PA)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:SCOTT
Last Name:AHLSTROM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1650 S TOPAZ WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4474
Mailing Address - Country:US
Mailing Address - Phone:208-605-7070
Mailing Address - Fax:
Practice Address - Street 1:7941 W RIFLEMAN ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9001
Practice Address - Country:US
Practice Address - Phone:208-895-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61522965363A00000X
IDPA-1715363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant