Provider Demographics
NPI:1932254133
Name:BAGLEY, BRETT GERALD (PA - CERTIFIED)
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:GERALD
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:PA - CERTIFIED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 TREJO ST STE 400
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5405
Mailing Address - Country:US
Mailing Address - Phone:208-359-2263
Mailing Address - Fax:208-359-2042
Practice Address - Street 1:556 TREJO ST
Practice Address - Street 2:SUITE B
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-215363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805069800Medicaid
ID201139500OtherTAX IDENTIFICATION