Provider Demographics
NPI:1184134843
Name:SHUMARD, ERIN MARIE
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:MARIE
Last Name:SHUMARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-985-1399
Mailing Address - Fax:
Practice Address - Street 1:3280 E LANARK DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5982
Practice Address - Country:US
Practice Address - Phone:208-377-4400
Practice Address - Fax:208-377-4416
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-09
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1542363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant