Healthcare Provider Details

I. General information

NPI: 1457865388
Provider Name (Legal Business Name): TY C WEBER FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 E LOCUST ST
EMMETT ID
83617-2713
US

IV. Provider business mailing address

1102 E LOCUST ST
EMMETT ID
83617-2713
US

V. Phone/Fax

Practice location:
  • Phone: 208-365-6004
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5671037
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201808187NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: