Provider Demographics
NPI:1407691835
Name:WOOLDRIDGE, ADDISON BROC (PA-C)
Entity type:Individual
Prefix:
First Name:ADDISON
Middle Name:BROC
Last Name:WOOLDRIDGE
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 1:9475 W TILLAMOOK DR # A
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6173
Mailing Address - Country:US
Mailing Address - Phone:661-205-1177
Mailing Address - Fax:
Practice Address - Street 1:9475 W TILLAMOOK DR # A
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-6173
Practice Address - Country:US
Practice Address - Phone:661-205-1177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant