Provider Demographics
NPI:1710305768
Name:ROE, TYLER (DO)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:ROE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 HILAND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-1564
Mailing Address - Country:US
Mailing Address - Phone:208-678-7246
Mailing Address - Fax:208-678-5833
Practice Address - Street 1:1344 HILAND AVE STE A
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318
Practice Address - Country:US
Practice Address - Phone:208-678-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-06
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ8621207L00000X
IDO-1201207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX388203701Medicaid
TX388203702OtherCSHCN