Provider Demographics
NPI:1205885092
Name:TRYON, THOMAS WAYNE (PA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:WAYNE
Last Name:TRYON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 W YOSEMITE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2598
Mailing Address - Country:US
Mailing Address - Phone:208-898-0845
Mailing Address - Fax:
Practice Address - Street 1:206 E ELM ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4815
Practice Address - Country:US
Practice Address - Phone:208-459-4511
Practice Address - Fax:208-459-6602
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA414363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806483200Medicaid
ID806483200Medicaid
IDQ12434Medicare UPIN