Provider Demographics
NPI:1194186437
Name:TABLE ROCK MOBILE MEDICINE PLLC
Entity Type:Organization
Organization Name:TABLE ROCK MOBILE MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BIGFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, NP-C
Authorized Official - Phone:986-224-8420
Mailing Address - Street 1:PO BOX 44953
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-0953
Mailing Address - Country:US
Mailing Address - Phone:986-224-8424
Mailing Address - Fax:208-504-2821
Practice Address - Street 1:1111 S ORCHARD ST STE 251
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1964
Practice Address - Country:US
Practice Address - Phone:986-224-8420
Practice Address - Fax:208-504-2821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-15
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1252A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty