Provider Demographics
NPI:1447296785
Name:BRUNSON, ZACHERY M (PA-C)
Entity type:Individual
Prefix:
First Name:ZACHERY
Middle Name:M
Last Name:BRUNSON
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 1:393 E 2ND N
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1605
Mailing Address - Country:US
Mailing Address - Phone:208-356-5401
Mailing Address - Fax:208-356-3111
Practice Address - Street 1:393 E 2ND N
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-356-5401
Practice Address - Fax:208-356-3111
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-607363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807432900Medicaid