Healthcare Provider Details

I. General information

NPI: 1043400484
Provider Name (Legal Business Name): MEDICAL IMAGING ASSOC OF IDAHO FALLS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY
POCATELLO ID
83201-5175
US

IV. Provider business mailing address

PO BOX 85495
CHICAGO IL
60689-5495
US

V. Phone/Fax

Practice location:
  • Phone: 208-227-2600
  • Fax:
Mailing address:
  • Phone: 208-715-5220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: KAREN MARIE VAUGHN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 330-309-6984