Healthcare Provider Details

I. General information

NPI: 1205885092
Provider Name (Legal Business Name): THOMAS WAYNE TRYON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 E ELM ST
CALDWELL ID
83605-4815
US

IV. Provider business mailing address

1031 W YOSEMITE DR
MERIDIAN ID
83642-2598
US

V. Phone/Fax

Practice location:
  • Phone: 208-459-4511
  • Fax: 208-459-6602
Mailing address:
  • Phone: 208-898-0845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA414
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: