Provider Demographics
NPI:1972805943
Name:RELYEA, RAMON ADDISON (PA-C)
Entity type:Individual
Prefix:
First Name:RAMON
Middle Name:ADDISON
Last Name:RELYEA
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 1:2301 E SADIE DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5409
Mailing Address - Country:US
Mailing Address - Phone:530-520-7796
Mailing Address - Fax:
Practice Address - Street 1:3224 N MAPLE GROVE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4214
Practice Address - Country:US
Practice Address - Phone:208-888-3358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-24
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60193367363AM0700X
UT10927277-1206363AM0700X
IDPA-1084363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical