MEDICARE: NEIL K BURRASTON DO

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	208D00000X	General Practice Physician	O-1960	ID
2	207Q00000X	Family Medicine Physician	O1960	ID

General Provider Information

NPI Number	:	1760131841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEIL K BURRASTON DO

Provider Business Mailing Address
First Line	:	2065 E 17TH ST STE A
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-8042
Country	:	US
Telephone Number	:	208-522-3301
Fax Number	:	208-522-3414

Provider Business Practice Location Address
First Line	:	2065 E 17TH ST STE A
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-8042
Country	:	US
Telephone Number	:	208-522-3301
Fax Number	:	208-522-3414

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

Provider Enumeration Date	:	03/23/2022
Last Update Date	:	06/01/2026

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Directions to “ NEIL K BURRASTON DO” Practice Location

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