Healthcare Provider Details

I. General information

NPI: 1275961765
Provider Name (Legal Business Name): BRENTON JAMES NOEL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2013
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 S MIDDLETON RD STE B
MIDDLETON ID
83644-5369
US

IV. Provider business mailing address

PO BOX 277976
ATLANTA GA
30384-7976
US

V. Phone/Fax

Practice location:
  • Phone: 208-585-6311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1102
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: