1356123863 NPI number — TYSON DARRELL GREENER PA-C

Table of content: (NPI 1487363214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356123863 NPI number — TYSON DARRELL GREENER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENER
Provider First Name:
TYSON
Provider Middle Name:
DARRELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356123863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
684 E 400 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUPERT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83350-9460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-670-7008
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
260 E 5TH ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-3453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-678-9760
Provider Business Practice Location Address Fax Number:
208-678-9758
Provider Enumeration Date:
10/18/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  6571244 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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