Basic Information
Provider Information | |||||||||
NPI: | 1184166886 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROTHWELL | ||||||||
FirstName: | TYSON | ||||||||
MiddleName: | TONY | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MOTR/L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 393 E 2ND N | ||||||||
Address2: |   | ||||||||
City: | REXBURG | ||||||||
State: | ID | ||||||||
PostalCode: | 834401605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083599570 | ||||||||
FaxNumber: | 2083599580 | ||||||||
Practice Location | |||||||||
Address1: | 393 E 2ND N | ||||||||
Address2: |   | ||||||||
City: | REXBURG | ||||||||
State: | ID | ||||||||
PostalCode: | 834401605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083599570 | ||||||||
FaxNumber: | 2083599580 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/11/2016 | ||||||||
LastUpdateDate: | 11/11/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT-1162 | ID | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.