Healthcare Provider Details

I. General information

NPI: 1326209537
Provider Name (Legal Business Name): NATHAN CHAD HANCOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 E MAIN ST
REXBURG ID
83440-2048
US

IV. Provider business mailing address

450 E MAIN ST
REXBURG ID
83440-2048
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-3691
  • Fax:
Mailing address:
  • Phone: 208-356-3691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberM-11499
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: