Healthcare Provider Details

I. General information

NPI: 1902739253
Provider Name (Legal Business Name): TANNER NATHAN STOHL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 CRESTWOOD LN
IDAHO FALLS ID
83404-4979
US

IV. Provider business mailing address

206 GETTYSBURG LN
IDAHO FALLS ID
83404-8423
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8581713
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: