Individual
MITCHELL ERIC BLUME
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C, RD, CDE
Contact information
Practice address
190 E BANNOCK ST, BOISE, ID 83712-6241
(208) 381-5015
Mailing address
190 E BANNOCK ST, BOISE, ID 83712-6241
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
PA-1517
ID
363AS0400X
Surgical Physician Assistant
Primary
PA-2266
ID
363AS0400X
Surgical Physician Assistant
PA60794259
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1710334248
—
ID
Enumeration date
05/13/2016
Last updated
06/30/2022
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