Healthcare Provider Details

I. General information

NPI: 1205587847
Provider Name (Legal Business Name): DALLON HIGGS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 N OVERLAND AVE
BURLEY ID
83318-3433
US

IV. Provider business mailing address

355 W 500 S
BURLEY ID
83318-5229
US

V. Phone/Fax

Practice location:
  • Phone: 208-678-6996
  • Fax:
Mailing address:
  • Phone: 208-520-1921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2182
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: