Healthcare Provider Details

I. General information

NPI: 1528623303
Provider Name (Legal Business Name): JEREMIAH D BUEHNER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 WINN DR
REXBURG ID
83440-5277
US

IV. Provider business mailing address

21 WINN DR
REXBURG ID
83440-5277
US

V. Phone/Fax

Practice location:
  • Phone: 208-881-5222
  • Fax: 877-441-4715
Mailing address:
  • Phone: 208-881-5222
  • Fax: 877-441-4715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5771348
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: