Healthcare Provider Details

I. General information

NPI: 1124462494
Provider Name (Legal Business Name): UPPER VALLEY ENT & ALLERGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 N 2ND E
REXBURG ID
83440-1638
US

IV. Provider business mailing address

256 N 2ND E
REXBURG ID
83440-1638
US

V. Phone/Fax

Practice location:
  • Phone: 208-656-9646
  • Fax: 208-656-9645
Mailing address:
  • Phone: 208-656-9646
  • Fax: 208-656-9645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JAY ROBERT MCMASTER
Title or Position: PHYSICIAN/SURGEON
Credential: DO
Phone: 208-656-9646