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General NPI Number Information
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NPI Number | 1629247093
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Entity Type | Organization
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Legal Business Name | FALL CREEK SKIN AND HEALTH PLLC
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Dates
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Enumeration Date | 02/29/2008
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Last Update Date | 06/26/2018
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Provider Practice Location Address
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Address Line | 534 TREJO ST STE 400
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City | REXBURG
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State | ID
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Zip | 83440
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Country | US
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Telephone | 208-359-2263
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Fax | 208-359-2042
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Provider Business Mailing Address
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Address Line | PO BOX 378
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City | REXBURG
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State | ID
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Zip | 83440-0378
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Country | US
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Telephone | 208-359-2263
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Fax | 208-359-2042
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT CERTIFIED
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Name | MR. BRETT GERALD BAGLEY
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Credential | P.A.-C.
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Telephone | 208-359-2263
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA-215
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License Number State | ID
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