Provider Demographics
NPI:1992091722
Name:WORTHINGTON, SKYLER S (PA-C)
Entity type:Individual
Prefix:
First Name:SKYLER
Middle Name:S
Last Name:WORTHINGTON
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:PO BOX 8007
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-0507
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:208-883-6580
Practice Address - Street 1:156 6TH ST
Practice Address - Street 2:
Practice Address - City:POTLATCH
Practice Address - State:ID
Practice Address - Zip Code:83855
Practice Address - Country:US
Practice Address - Phone:208-875-2380
Practice Address - Fax:208-875-2303
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1825363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1098068OtherNCCPA
OR500655834Medicaid
1098068OtherNCCPA
OR500655834Medicaid