Provider Demographics
NPI:1194909598
Name:RASCH, GLADYS MARIE (MPA-C)
Entity type:Individual
Prefix:MS
First Name:GLADYS
Middle Name:MARIE
Last Name:RASCH
Suffix:
Gender:F
Credentials:MPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 SHOUP AVE W
Mailing Address - Street 2:SUITE #E
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5043
Mailing Address - Country:US
Mailing Address - Phone:120-873-4590
Mailing Address - Fax:208-734-9502
Practice Address - Street 1:496 SHOUP AVE W
Practice Address - Street 2:SUITE #E
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5043
Practice Address - Country:US
Practice Address - Phone:208-733-2885
Practice Address - Fax:208-734-3352
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-199363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDS40522Medicare UPIN
ID16652551Medicare PIN