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General NPI Number Information
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NPI Number | 1639151848
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Entity Type | Individual
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Provider Name | TRUDY BEARDEN PA-C
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Gender | Female
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Dates
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Enumeration Date | 11/15/2005
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Last Update Date | 08/01/2009
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Provider Practice Location Address
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Address Line | 465 MEMORIAL DR
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City | POCATELLO
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State | ID
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Zip | 83209-0001
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Country | US
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Telephone | 208-282-4700
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Fax |
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Provider Business Mailing Address
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Address Line | 465 MEMORIAL DR
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City | POCATELLO
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State | ID
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Zip | 83201-4008
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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-543
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License Number State | ID
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