Provider Demographics
NPI:1871311647
Name:DERMATOLOGY AND ALLERGIES CLINIC AT TETON VALLEY PLLC
Entity type:Organization
Organization Name:DERMATOLOGY AND ALLERGIES CLINIC AT TETON VALLEY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYUDMYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:NORGART
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:813-230-4241
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-0967
Mailing Address - Country:US
Mailing Address - Phone:813-230-4241
Mailing Address - Fax:
Practice Address - Street 1:40 E LITTLE AVE
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5138
Practice Address - Country:US
Practice Address - Phone:208-354-8220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty