Healthcare Provider Details

I. General information

NPI: 1003461401
Provider Name (Legal Business Name): NOAH BERNAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2019
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3614 WASHINGTON PKWY
IDAHO FALLS ID
83404-7573
US

IV. Provider business mailing address

6410 E MANSION HILL DR
AMMON ID
83406-4707
US

V. Phone/Fax

Practice location:
  • Phone: 208-535-4343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPA-1924
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: