Provider Demographics
NPI:1215949532
Name:ANDRUS, CARL RYAN (PA)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:RYAN
Last Name:ANDRUS
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 1:4902 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3326
Mailing Address - Country:US
Mailing Address - Phone:208-853-3100
Mailing Address - Fax:208-853-3120
Practice Address - Street 1:4902 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-3326
Practice Address - Country:US
Practice Address - Phone:208-853-3100
Practice Address - Fax:208-853-3120
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010157032OtherBLUE CROSS
ID807520000Medicaid
IDPAD25OtherBLUE CROSS
ID000010157033OtherBLUE SHIELD
IDPAD26OtherBLUE CROSS