Healthcare Provider Details

I. General information

NPI: 1285563841
Provider Name (Legal Business Name): MIKELL BRYNN GIBBONS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIKELL BRYNN WEAVER

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 ELK CREEK DR
IDAHO FALLS ID
83404-8322
US

IV. Provider business mailing address

1550 ELK CREEK DR
IDAHO FALLS ID
83404-8322
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-5942
  • Fax: 208-529-5951
Mailing address:
  • Phone: 208-529-5942
  • Fax: 208-529-5951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number7181719
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: