Provider Demographics
NPI:1548245236
Name:DYE, PAUL M (MPT, MOTR/L, ATC,)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:M
Last Name:DYE
Suffix:
Gender:M
Credentials:MPT, MOTR/L, ATC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WINN DRIVE
Mailing Address - Street 2:SUITE #100
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440
Mailing Address - Country:US
Mailing Address - Phone:208-356-0174
Mailing Address - Fax:208-356-0176
Practice Address - Street 1:36 WINN DRIVE
Practice Address - Street 2:SUITE #100
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-356-0174
Practice Address - Fax:208-356-0176
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1920225100000X
ID711225X00000X
IDPT-1920225100000X
IDAT-1422255A2300X
IDOT-711225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID887408OtherDMBA
ID807100400Medicaid
ID80710500Medicaid
ID1551727Medicare ID - Type Unspecified
ID807100400Medicaid