Provider Demographics
NPI:1164581849
Name:BYRNE, THOMAS J (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:BYRNE
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:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:208-625-2070
Practice Address - Street 1:109 E HARRISON AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3238
Practice Address - Country:US
Practice Address - Phone:208-292-0281
Practice Address - Fax:844-807-3877
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004704363A00000X
IDPA167363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8406456Medicaid
P00216067OtherRAILROAD MCR
ID1030537OtherNCCPA
WA8852849Medicare PIN