Skinlab 360 Dermatology & Aesthetics LLC

Primary specialty

Physician AssistantTaxonomy code 363A00000X

Legal business name

SKINLAB 360 DERMATOLOGY & AESTHETICS LLC

Practice address

117 W Main St Ste 101
Rexburg, ID 83440-1826

Phone

(208) 709-0478

NPI assigned

Apr 26, 2021

Last updated

Apr 26, 2021By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Julie Anderson, PA-CNPI 1215237896

Title

Owner

Phone

(208) 709-0478

Specialties & licenses 1

Addresses

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Julie Marie Anderson, P.A.

  • Physician Assistant
  • Rexburg, ID
  • NPI 1215237896
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1619395200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1619395200000",
    "number": "1376125740",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3625",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834033625",
            "telephone_number": "800-338-5378",
            "fax_number": "208-523-8978"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "117 W MAIN ST STE 101",
            "city": "REXBURG",
            "state": "ID",
            "postal_code": "834401826",
            "telephone_number": "208-709-0478"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SKINLAB 360 DERMATOLOGY & AESTHETICS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-04-26",
        "last_updated": "2021-04-26",
        "certification_date": "2021-04-26",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "JULIE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "208-709-0478",
        "authorized_official_credential": "PA-C"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Alicia G Siddoway, RPT
• Matthew Galland Silva
• Gracie Allene Simmons
• Stephanie Ann Sims
• Steven G Sjoblom, CCC-SLP
• Brandi E Slachter, BSRPH
• Sleep DDS LLC (Bauer Family Dental)
• Alan R Smith, D.C.
• Christopher James Smith, PHARMD
• Douglas 'J' Smith, DDS

• Physician Assistant in Rexburg, ID
• Providers in Rexburg, ID by specialty
• Physician Assistant in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 26, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.