Provider Demographics
NPI:1962832923
Name:BELNAP, DALE MCKAY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:MCKAY
Last Name:BELNAP
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 HOSPITAL WAY STE 710
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2745
Mailing Address - Country:US
Mailing Address - Phone:208-235-4263
Mailing Address - Fax:208-233-4268
Practice Address - Street 1:444 HOSPITAL WAY STE 710
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2745
Practice Address - Country:US
Practice Address - Phone:208-235-4263
Practice Address - Fax:208-233-4268
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTLP-019363AS0400X
IDPA-1133363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
20004203Medicare UPIN