Healthcare Provider Details

I. General information

NPI: 1124451554
Provider Name (Legal Business Name): ASHLEY TYNER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12072 W MCMILLAN RD
BOISE ID
83713-2462
US

IV. Provider business mailing address

12072 W MCMILLAN RD
BOISE ID
83713-2462
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-0533
  • Fax: 208-939-3341
Mailing address:
  • Phone: 208-939-0533
  • Fax: 208-939-3341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT-3262
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: