Healthcare Provider Details

I. General information

NPI: 1730222365
Provider Name (Legal Business Name): BRETT W ZUNDEL P.A-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1286 E 1500 N
TERRETON ID
83450
US

IV. Provider business mailing address

21 WINN DR P.O. BOX 69
REXBURG ID
83440-5277
US

V. Phone/Fax

Practice location:
  • Phone: 208-663-4628
  • Fax: 208-663-4922
Mailing address:
  • Phone: 208-663-4628
  • Fax: 208-663-4922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA197
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: