Healthcare Provider Details

I. General information

NPI: 1588995435
Provider Name (Legal Business Name): TYLER DONALD COBURN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

PO BOX 7411114
CHICAGO IL
60674-1114
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6416
  • Fax: 208-367-2742
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberTEMP 21060
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA-766
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: