Individual
KATIE DIANE MADDOCK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1550 ELK CREEK DR, IDAHO FALLS, ID 83404-8322
(208) 529-5942
Mailing address
1550 ELK CREEK DR, IDAHO FALLS, ID 83404-8322
(208) 529-5942
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0002896036
—
ID
Enumeration date
08/10/2022
Last updated
11/23/2024
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