1730222365 NPI number — BRETT W ZUNDEL P.A-C

Table of content: BRETT W ZUNDEL P.A-C (NPI 1730222365)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730222365 NPI number — BRETT W ZUNDEL P.A-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ZUNDEL
Provider First Name:
BRETT
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730222365
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 WINN DR
Provider Second Line Business Mailing Address:
P.O. BOX 69
Provider Business Mailing Address City Name:
REXBURG
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83440-5277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-663-4628
Provider Business Mailing Address Fax Number:
208-663-4922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1286 E 1500 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRETON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-663-4628
Provider Business Practice Location Address Fax Number:
208-663-4922
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA197 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0007309726 . This is a "AETNA" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010006458 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: PAYL7 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 805130800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com