Healthcare Provider Details

I. General information

NPI: 1962832923
Provider Name (Legal Business Name): DALE MCKAY BELNAP PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 HOSPITAL WAY STE 710
POCATELLO ID
83201-2745
US

IV. Provider business mailing address

444 HOSPITAL WAY STE 710
POCATELLO ID
83201-2745
US

V. Phone/Fax

Practice location:
  • Phone: 208-235-4263
  • Fax: 208-233-4268
Mailing address:
  • Phone: 208-235-4263
  • Fax: 208-233-4268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberTLP-019
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-1133
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: