Provider Demographics
NPI:1437765088
Name:STAUFFER, AMANDA L (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:STAUFFER
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 N 1ST ST STE 250
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6132
Practice Address - Country:US
Practice Address - Phone:208-381-9384
Practice Address - Fax:208-381-9385
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2465363A00000X
IDPA-2806363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant