Healthcare Provider Details

I. General information

NPI: 1588754162
Provider Name (Legal Business Name): DAVID L. BUDGE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 S MAIN ST
HAILEY ID
83333-8929
US

IV. Provider business mailing address

740 S WOODRUFF AVE
IDAHO FALLS ID
83401-5285
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-9111
  • Fax: 208-542-9114
Mailing address:
  • Phone: 208-542-9111
  • Fax: 208-542-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number330483-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1611
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: