Healthcare Provider Details

I. General information

NPI: 1760131841
Provider Name (Legal Business Name): NEIL K BURRASTON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 E 17TH ST STE A
IDAHO FALLS ID
83404-8042
US

IV. Provider business mailing address

2065 E 17TH ST STE A
IDAHO FALLS ID
83404-8042
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-3301
  • Fax: 208-522-3414
Mailing address:
  • Phone: 208-522-3301
  • Fax: 208-522-3414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberO-1960
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO1960
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: