Provider Demographics
NPI:1992485544
Name:JEPPSON, LEVI (PA-C)
Entity type:Individual
Prefix:
First Name:LEVI
Middle Name:
Last Name:JEPPSON
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 1:2315 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-7301
Mailing Address - Country:US
Mailing Address - Phone:208-746-1383
Mailing Address - Fax:
Practice Address - Street 1:320 WARNER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4441
Practice Address - Country:US
Practice Address - Phone:208-743-3523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
ID7661573363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant