Healthcare Provider Details

I. General information

NPI: 1760533400
Provider Name (Legal Business Name): DALLIN BRIM GAMBLES PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 WALKER DR
REXBURG ID
83440-1657
US

IV. Provider business mailing address

380 WALKER DRIVE
REXBURG ID
83440
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-9559
  • Fax:
Mailing address:
  • Phone: 208-356-9559
  • Fax: 208-356-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-236
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: