Individual
CARL RYAN ANDRUS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.
Contact information
Practice address
4902 W STATE ST, BOISE, ID 83703-3326
(208) 853-3100
(208) 853-3120
Mailing address
4902 W STATE ST, BOISE, ID 83703-3326
(208) 853-3100
(208) 853-3120
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA-508
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010157032
BLUE CROSS
ID
01
—
000010157033
BLUE SHIELD
ID
05
—
807520000
—
ID
01
—
PAD25
BLUE CROSS
ID
01
—
PAD26
BLUE CROSS
ID
Enumeration date
08/13/2006
Last updated
07/08/2007
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