Healthcare Provider Details

I. General information

NPI: 1447296785
Provider Name (Legal Business Name): ZACHERY M BRUNSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 E 2ND N
REXBURG ID
83440
US

IV. Provider business mailing address

393 E 2ND N
REXBURG ID
83440-1605
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-5401
  • Fax: 208-356-3111
Mailing address:
  • Phone: 208-356-5401
  • Fax: 208-356-3111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-607
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: