Provider Demographics
NPI:1215690474
Name:WIEBOLD, KURT (PA)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:WIEBOLD
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 1:6140 W CURTISIAN AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8907
Mailing Address - Country:US
Mailing Address - Phone:208-327-5600
Mailing Address - Fax:208-327-5602
Practice Address - Street 1:6140 W CURTISIAN AVE STE 400
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8907
Practice Address - Country:US
Practice Address - Phone:208-327-5600
Practice Address - Fax:208-327-5602
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant