Provider Demographics
NPI:1811022056
Name:CHRISTENSEN, BRIAN WADE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:WADE
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MADISON PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2058
Mailing Address - Country:US
Mailing Address - Phone:208-656-9008
Mailing Address - Fax:208-656-0999
Practice Address - Street 1:20 MADISON PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2058
Practice Address - Country:US
Practice Address - Phone:208-656-9008
Practice Address - Fax:208-656-0999
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7414208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDDT307OtherBLUE SHIELD
ID000010004529OtherBLUE CROSS
IDG63559Medicare UPIN
ID1138736Medicare ID - Type UnspecifiedMEDICARE