Provider Demographics
NPI:1124092101
Name:BICKFORD, ALBERT DONALD (PA-C)
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:DONALD
Last Name:BICKFORD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-8550
Mailing Address - Fax:208-367-8555
Practice Address - Street 1:3025 W CHERRY LANE
Practice Address - Street 2:STE B
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1026
Practice Address - Country:US
Practice Address - Phone:208-367-8550
Practice Address - Fax:208-367-8555
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1666755Medicare ID - Type Unspecified
ID805850700Medicaid
P18866Medicare UPIN