Provider Demographics
NPI:1073542056
Name:TEZENO-BURRIS, PHYLLIS D (NP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:D
Last Name:TEZENO-BURRIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 W OCEANO BELLO DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6983
Mailing Address - Country:US
Mailing Address - Phone:310-613-2235
Mailing Address - Fax:
Practice Address - Street 1:1000 E PARK BLVD STE 120
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-7793
Practice Address - Country:US
Practice Address - Phone:208-381-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP9976363L00000X
ID57502363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P36353Medicare UPIN