Provider Demographics
NPI:1912138231
Name:BURCHAM, TYLER (DPT)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:BURCHAM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 S CAROL ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1839
Mailing Address - Country:US
Mailing Address - Phone:208-288-1155
Mailing Address - Fax:208-288-0424
Practice Address - Street 1:3170 43RD ST S
Practice Address - Street 2:SUITE 101
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8908
Practice Address - Country:US
Practice Address - Phone:701-277-8448
Practice Address - Fax:701-277-8668
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1738225100000X
IDPT2542174400000X
IDPT-2542225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist