Healthcare Provider Details

I. General information

NPI: 1164044962
Provider Name (Legal Business Name): STERLING PROVIDER GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1952 HARRISON DR STE 1
EVANSTON WY
82930-3241
US

IV. Provider business mailing address

740 S WOODRUFF AVE
IDAHO FALLS ID
83401-5285
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-9111
  • Fax: 208-542-9114
Mailing address:
  • Phone: 208-542-9111
  • Fax: 208-542-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CORBIN BUNNAGE
Title or Position: PROVIDER/OWNER
Credential: PA-C
Phone: 208-542-9111