Provider Demographics
NPI:1306055850
Name:FORD, NANETTE CORNISH (PA C)
Entity type:Individual
Prefix:MS
First Name:NANETTE
Middle Name:CORNISH
Last Name:FORD
Suffix:
Gender:F
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:PO BOX 1575
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340
Mailing Address - Country:US
Mailing Address - Phone:208-725-0900
Mailing Address - Fax:208-725-0901
Practice Address - Street 1:180 EAST AVENUE
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-725-0900
Practice Address - Fax:208-725-0901
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA126OtherSTATE LICENSE