Healthcare Provider Details

I. General information

NPI: 1093073926
Provider Name (Legal Business Name): TARYN MICHELLE GRATTIC PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2012
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 W SUNSET AVE
COEUR D ALENE ID
83815-8305
US

IV. Provider business mailing address

214 W SUNSET AVE
COEUR D ALENE ID
83815-8305
US

V. Phone/Fax

Practice location:
  • Phone: 208-758-7878
  • Fax: 800-649-4171
Mailing address:
  • Phone: 208-758-7878
  • Fax: 800-649-4171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-982
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: