MEDICARE: DEREK BERTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	3371894	ID

General Provider Information

NPI Number	:	1114572716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK BERTA

Provider Business Mailing Address
First Line	:	PO BOX 277381
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-7381
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2860 CHANNING WAY STE 220
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7541
Country	:	US
Telephone Number	:	208-800-6155
Fax Number	:	208-800-6158

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2019
Last Update Date	:	03/17/2026

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Directions to “ DEREK BERTA ” Practice Location

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