Provider Demographics
NPI:1033391396
Name:ERLEBACH, TYRELL C (PA-C)
Entity Type:Individual
Prefix:
First Name:TYRELL
Middle Name:C
Last Name:ERLEBACH
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 1:3340 EAST GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:6140 W. CURTISIAN STE 102
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-0109
Practice Address - Country:US
Practice Address - Phone:208-367-7787
Practice Address - Fax:208-367-7798
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01031363A00000X
ORPA01464363A00000X
IDPA-816363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
2771092Medicare PIN