MEDICARE: MR. DEVON E. DAHLKE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician	5703274-1206	UT
2	363A00000X	Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	$$$$$$$$$	OTHER	UT	CHAMPUS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598866691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DEVON E. DAHLKE PA-C

Provider Business Mailing Address
First Line	:	740 S WOODRUFF AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-5285
Country	:	US
Telephone Number	:	208-542-9111
Fax Number	:	208-542-9114

Provider Business Practice Location Address
First Line	:	630 E 1400 N STE 150
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-2549
Country	:	US
Telephone Number	:	435-915-4465
Fax Number	:	435-514-4556

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	12/01/2020

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Directions to “ MR. DEVON E. DAHLKE PA-C” Practice Location

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