Provider Demographics
NPI:1063795789
Name:VETTER, GRETCHEN (PA)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:VETTER
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:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:6051 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8969
Practice Address - Country:US
Practice Address - Phone:208-302-5150
Practice Address - Fax:208-302-5155
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACBRE BRIO174H00000X
NVPBI CPES CERTIFIED175L00000X
363A00000X, 390200000X
IDPA-2456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No174H00000XOther Service ProvidersHealth Educator
No175L00000XOther Service ProvidersHomeopath
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program