Healthcare Provider Details

I. General information

NPI: 1043178650
Provider Name (Legal Business Name): SUMMIT DERMCARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N 12TH AVE
POCATELLO ID
83201-4742
US

IV. Provider business mailing address

707 N 12TH AVE
POCATELLO ID
83201-4742
US

V. Phone/Fax

Practice location:
  • Phone: 208-228-5600
  • Fax: 949-909-2202
Mailing address:
  • Phone: 208-228-5600
  • Fax: 949-909-2202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: TRAVIS GILBERT
Title or Position: OWNER
Credential: PA-C
Phone: 208-228-5600