Provider Demographics
NPI:1356123863
Name:GREENER, TYSON DARRELL (PA-C)
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:DARRELL
Last Name:GREENER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:684 E 400 N
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-9460
Mailing Address - Country:US
Mailing Address - Phone:208-670-7008
Mailing Address - Fax:
Practice Address - Street 1:260 E 5TH ST N
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-3453
Practice Address - Country:US
Practice Address - Phone:208-678-9760
Practice Address - Fax:208-678-9758
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6571244363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant