Provider Demographics
NPI:1154363000
Name:PERIUS, NICHOLAS J (PA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:PERIUS
Suffix:
Gender:M
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 409
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0409
Mailing Address - Country:US
Mailing Address - Phone:208-732-3429
Mailing Address - Fax:208-732-3220
Practice Address - Street 1:650 ADDISON AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5444
Practice Address - Country:US
Practice Address - Phone:208-732-3429
Practice Address - Fax:208-732-3220
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP03731Medicare UPIN