Healthcare Provider Details

I. General information

NPI: 1235549932
Provider Name (Legal Business Name): ZACHARY T MIGEL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 09/21/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 DOC PERKES RD
AFTON WY
83110-7703
US

IV. Provider business mailing address

740 S WOODRUFF AVE
IDAHO FALLS ID
83401-5285
US

V. Phone/Fax

Practice location:
  • Phone: 307-885-3637
  • Fax: 307-885-3638
Mailing address:
  • Phone: 208-542-9111
  • Fax: 208-542-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60463399
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA799
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: