Provider Demographics
NPI:1528808417
Name:PAKOOTAS, TOMMIA
Entity type:Individual
Prefix:
First Name:TOMMIA
Middle Name:
Last Name:PAKOOTAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 683
Mailing Address - Street 2:
Mailing Address - City:PLUMMER
Mailing Address - State:ID
Mailing Address - Zip Code:83851-0683
Mailing Address - Country:US
Mailing Address - Phone:208-301-3700
Mailing Address - Fax:
Practice Address - Street 1:875 PERIMETER DR
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-9803
Practice Address - Country:US
Practice Address - Phone:208-885-2182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program