Provider Demographics
NPI:1538476239
Name:STEWART, TYLER S (PA)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:S
Last Name:STEWART
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-345-6545
Mailing Address - Fax:208-345-1213
Practice Address - Street 1:333 N 1ST ST
Practice Address - Street 2:STE 280
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6100
Practice Address - Country:US
Practice Address - Phone:208-345-6545
Practice Address - Fax:208-345-1213
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000859Medicare PIN