Provider Demographics
NPI:1629247093
Name:FALL CREEK SKIN AND HEALTH PLLC
Entity type:Organization
Organization Name:FALL CREEK SKIN AND HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT CERTIFIED
Authorized Official - Prefix:MR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-359-2263
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0378
Mailing Address - Country:US
Mailing Address - Phone:208-359-2263
Mailing Address - Fax:208-359-2042
Practice Address - Street 1:534 TREJO ST STE 400
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-359-2263
Practice Address - Fax:208-359-2042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-215363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805069800Medicaid
IDS48159Medicare UPIN