Healthcare Provider Details

I. General information

NPI: 1679737217
Provider Name (Legal Business Name): UPPER VALLEY FAMILY MEDICINE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 RIGBY LAKE DR
RIGBY ID
83442-1271
US

IV. Provider business mailing address

530 RIGBY LAKE DR
RIGBY ID
83442-1271
US

V. Phone/Fax

Practice location:
  • Phone: 208-745-5021
  • Fax: 208-745-5026
Mailing address:
  • Phone: 208-745-5021
  • Fax: 208-745-5026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: CONNIE LYNN SAFARIK
Title or Position: OFFICE MANAGER
Credential: CPC
Phone: 208-745-6717