Provider Demographics
NPI:1386944304
Name:POULSEN, TESSA (PA-C)
Entity type:Individual
Prefix:MS
First Name:TESSA
Middle Name:
Last Name:POULSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:TESSA
Other - Middle Name:A
Other - Last Name:WHITELEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1404 POMERELLE AVE
Mailing Address - Street 2:STE B
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2013
Mailing Address - Country:US
Mailing Address - Phone:208-734-3312
Mailing Address - Fax:208-734-5036
Practice Address - Street 1:325 MARTIN ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4563
Practice Address - Country:US
Practice Address - Phone:208-734-0451
Practice Address - Fax:208-734-0452
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21275363A00000X
ID363A00000X
IDPA-1002363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant