Provider Demographics
NPI:1497448716
Name:GREENER, TYLER AUSTIN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:AUSTIN
Last Name:GREENER
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1739 S JADE WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5898
Mailing Address - Country:US
Mailing Address - Phone:208-207-5454
Mailing Address - Fax:208-600-6064
Practice Address - Street 1:1739 S JADE WAY STE 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5898
Practice Address - Country:US
Practice Address - Phone:208-207-5454
Practice Address - Fax:208-600-6064
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist