Provider Demographics
NPI:1033641154
Name:JUE, TYLER (NP)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:JUE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-2202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:208-302-0855
Practice Address - Street 1:645 E 5TH ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2202
Practice Address - Country:US
Practice Address - Phone:208-549-0370
Practice Address - Fax:208-302-0855
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55104363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner