Healthcare Provider Details

I. General information

NPI: 1114572716
Provider Name (Legal Business Name): DEREK BERTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 CHANNING WAY STE 220
IDAHO FALLS ID
83404-7541
US

IV. Provider business mailing address

PO BOX 277381
ATLANTA GA
30384-7381
US

V. Phone/Fax

Practice location:
  • Phone: 208-800-6155
  • Fax: 208-800-6158
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3371894
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: