Healthcare Provider Details

I. General information

NPI: 1003949298
Provider Name (Legal Business Name): IDAHO ALLERGY & ASTHMA CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3422 S 15TH E
IDAHO FALLS ID
83404-8262
US

IV. Provider business mailing address

3422 S 15TH E
IDAHO FALLS ID
83404-8262
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-9292
  • Fax: 208-523-2397
Mailing address:
  • Phone: 208-529-9292
  • Fax: 208-523-2397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WENDELL E PETTY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 208-529-9292