Healthcare Provider Details

I. General information

NPI: 1396715371
Provider Name (Legal Business Name): TROY D WESTON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E HOWARD ST TETON VALLEY HEALTH CARE
DRIGGS ID
83422-5112
US

IV. Provider business mailing address

120 E HOWARD ST TETON VALLEY HEALTH CARE
DRIGGS ID
83422-5112
US

V. Phone/Fax

Practice location:
  • Phone: 208-354-6302
  • Fax: 208-354-3158
Mailing address:
  • Phone: 208-354-6302
  • Fax: 208-354-3158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA212
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 212
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: