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General NPI Number Information
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NPI Number | 1003949298
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Entity Type | Organization
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Legal Business Name | IDAHO ALLERGY & ASTHMA CLINIC PA
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 06/21/2019
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Provider Practice Location Address
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Address Line | 3422 S 15TH E
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8262
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Country | US
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Telephone | 208-529-9292
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Fax | 208-523-2397
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Provider Business Mailing Address
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Address Line | 3422 S 15TH E
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8262
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Country | US
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Telephone | 208-529-9292
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Fax | 208-523-2397
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. WENDELL E PETTY
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Credential | M.D.
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Telephone | 208-529-9292
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number |
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License Number State |
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