Provider Demographics
NPI:1386635977
Name:CHURCH, NATHAN JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:JOHN
Last Name:CHURCH
Suffix:
Gender:M
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 1:6052 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-2739
Mailing Address - Country:US
Mailing Address - Phone:208-344-7799
Mailing Address - Fax:208-344-7152
Practice Address - Street 1:6052 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-2739
Practice Address - Country:US
Practice Address - Phone:208-344-7799
Practice Address - Fax:208-344-7152
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-266363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA-266OtherSTATE LISCENSE
ORPA00678OtherOR STATE LISCENSE
P00873Medicare UPIN
ID1664190Medicare ID - Type Unspecified