Individual
CARLY PETRIE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
520 S EAGLE RD STE 1241, MERIDIAN, ID 83642-6355
(208) 381-6930
Mailing address
190 E BANNOCK ST, BOISE, ID 83712-6241
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
PA-2393
ID
363AS0400X
Surgical Physician Assistant
—
ID
Other
Enumeration date
10/17/2022
Last updated
11/11/2022
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