Healthcare Provider Details

I. General information

NPI: 1891654497
Provider Name (Legal Business Name): TAYLOR JAMES THOMASON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 MEMORIAL DR BLDG 83
POCATELLO ID
83201-4008
US

IV. Provider business mailing address

441 JORDAN LOOP
CHUBBUCK ID
83202-1655
US

V. Phone/Fax

Practice location:
  • Phone: 208-282-6000
  • Fax:
Mailing address:
  • Phone: 208-521-6843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: