Provider Demographics
NPI:1386756849
Name:RADIMER, ANGELA HOFFMAN (PA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:HOFFMAN
Last Name:RADIMER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:CHRISTINA
Other - Last Name:HOFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:500 W. FORT ST
Mailing Address - Street 2:# 111
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-422-1000
Mailing Address - Fax:208-422-1319
Practice Address - Street 1:500 W. FORT ST
Practice Address - Street 2:# 111
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:208-422-1319
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0102771363A00000X
ORPA01350363A00000X
IDPA736363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA736OtherSTATE OF IDAHO
ORPA01350OtherSTATE OF OREGON
ID16650992Medicare PIN
Q38499Medicare UPIN
ID1665099Medicare PIN
ORPA01350OtherSTATE OF OREGON
ORR141284Medicare PIN
IDPA736OtherSTATE OF IDAHO
ORR141285Medicare PIN