Healthcare Provider Details

I. General information

NPI: 1033583117
Provider Name (Legal Business Name): TYSON DANIEL COOK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2015
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N CURTIS RD SUITE 204
BOISE ID
83706-1338
US

IV. Provider business mailing address

7550 W EMERALD ST
BOISE ID
83704-9015
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-3315
  • Fax:
Mailing address:
  • Phone: 208-314-5904
  • Fax: 208-375-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-4239
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: