Provider Demographics
NPI:1730222365
Name:ZUNDEL, BRETT W (PA-C)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:W
Last Name:ZUNDEL
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 1:21 WINN DR
Mailing Address - Street 2:P.O. BOX 69
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5277
Mailing Address - Country:US
Mailing Address - Phone:208-663-4628
Mailing Address - Fax:208-663-4922
Practice Address - Street 1:1286 E 1500 N
Practice Address - Street 2:
Practice Address - City:TERRETON
Practice Address - State:ID
Practice Address - Zip Code:83450
Practice Address - Country:US
Practice Address - Phone:208-663-4628
Practice Address - Fax:208-663-4922
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA197363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0007309726OtherAETNA
ID000010006458OtherBLUE SHIELD
IDPAYL7OtherBLUE CROSS
ID805130800Medicaid
ID0007309726OtherAETNA
ID1133896Medicare ID - Type Unspecified