Provider Demographics
NPI:1790131480
Name:MCKINNON, TYLER JORDAN (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JORDAN
Last Name:MCKINNON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7733 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9020
Mailing Address - Country:US
Mailing Address - Phone:801-866-6753
Mailing Address - Fax:208-939-5010
Practice Address - Street 1:7733 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9020
Practice Address - Country:US
Practice Address - Phone:208-376-3220
Practice Address - Fax:208-939-5010
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2018-04-19
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant