Provider Demographics
NPI:1467252155
Name:IMPERIO, PATRICK EDWARD
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:EDWARD
Last Name:IMPERIO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:381 S MIDDLETON RD STE B
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-5369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:381 S MIDDLETON RD STE B
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-5369
Practice Address - Country:US
Practice Address - Phone:208-585-6311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6071156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant