Provider Demographics
NPI:1366510752
Name:SUNDQUIST, CHRISTOPHER RAY (PAC)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:RAY
Last Name:SUNDQUIST
Suffix:
Gender:M
Credentials:PAC
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 775
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:ID
Mailing Address - Zip Code:83801
Mailing Address - Country:US
Mailing Address - Phone:208-683-0800
Mailing Address - Fax:208-683-0900
Practice Address - Street 1:6101 W HWY 54
Practice Address - Street 2:SUITE A
Practice Address - City:ATHOL
Practice Address - State:ID
Practice Address - Zip Code:83801
Practice Address - Country:US
Practice Address - Phone:208-683-0800
Practice Address - Fax:208-683-0900
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-303363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPAD92OtherBLUE CROSS PIN
ID000010158675OtherREGENCE PIN
IDP23313Medicare UPIN
ID000010158675OtherREGENCE PIN