Basic Information
| Provider Information | |||||||||
| NPI: | 1699170688 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THORPE | ||||||||
| FirstName: | TYSON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3648 | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838162522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086205210 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1130 W PRAIRIE AVE | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838158780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082090288 | ||||||||
| FaxNumber: | 2082090289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2014 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0004137 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA-1423 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.