Provider Demographics
NPI:1598866691
Name:DAHLKE, DEVON E (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DEVON
Middle Name:E
Last Name:DAHLKE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5285
Mailing Address - Country:US
Mailing Address - Phone:208-542-9111
Mailing Address - Fax:208-542-9114
Practice Address - Street 1:630 E 1400 N STE 150
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2549
Practice Address - Country:US
Practice Address - Phone:435-915-4465
Practice Address - Fax:435-514-4556
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5703274-1206207PE0004X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$OtherCHAMPUS
UT1598866691Medicaid
UTQ32577Medicare UPIN
UTP00457917Medicare PIN