Healthcare Provider Details

I. General information

NPI: 1669927000
Provider Name (Legal Business Name): TYLER HASKELL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1967 N CAIRNS WAY
MERIDIAN ID
83646-1360
US

IV. Provider business mailing address

12072 W MCMILLAN RD
BOISE ID
83713-2462
US

V. Phone/Fax

Practice location:
  • Phone: 208-406-1968
  • Fax:
Mailing address:
  • Phone: 208-939-0533
  • Fax: 208-939-3341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4640
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-4640
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: