Healthcare Provider Details

I. General information

NPI: 1578742615
Provider Name (Legal Business Name): ROGER DAVID CUSHMAN P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 E. TERRY STREET
POCATELLO ID
83201
US

IV. Provider business mailing address

PO BOX 335
POCATELLO ID
83204-0335
US

V. Phone/Fax

Practice location:
  • Phone: 208-235-5910
  • Fax:
Mailing address:
  • Phone: 208-235-5910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberGPA-034
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: