Individual
MR. BRETT GERALD BAGLEY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
P.A. - CERTIFIED
Contact information
Practice address
556 TREJO ST, SUITE B, REXBURG, ID 83440
(208) 359-2263
(208) 359-2042
Mailing address
534 TREJO ST STE 400, REXBURG, ID 83440-5405
(208) 359-2263
(208) 359-2042
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA-215
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
201139500
TAX IDENTIFICATION
ID
05
—
805069800
—
ID
Enumeration date
01/25/2007
Last updated
06/26/2018
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