Healthcare Provider Details

I. General information

NPI: 1295402089
Provider Name (Legal Business Name): MARK ALAN ELLETT AGACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 CHANNING WAY
IDAHO FALLS ID
83404-7533
US

IV. Provider business mailing address

3817 NORA ST
POCATELLO ID
83204-2023
US

V. Phone/Fax

Practice location:
  • Phone: 208-604-1715
  • Fax:
Mailing address:
  • Phone: 208-604-1715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number69540
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number45067
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: