Provider Demographics
NPI:1679206312
Name:CHRISTESEN, CELESTE RENEE (PA-C)
Entity type:Individual
Prefix:
First Name:CELESTE
Middle Name:RENEE
Last Name:CHRISTESEN
Suffix:
Gender:
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-8752
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST FL 10
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-5500
Practice Address - Fax:208-381-2555
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDID000033431E376K00000X
390200000X
ID8761579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No376K00000XNursing Service Related ProvidersNurse's Aide
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program