Healthcare Provider Details

I. General information

NPI: 1316890270
Provider Name (Legal Business Name): IDAHO UROLOGY 1 PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MADISON PROFESSIONAL PARK
REXBURG ID
83440-2058
US

IV. Provider business mailing address

30 MADISON PROFESSIONAL PARK
REXBURG ID
83440-2058
US

V. Phone/Fax

Practice location:
  • Phone: 208-351-6363
  • Fax:
Mailing address:
  • Phone: 208-356-0004
  • Fax: 208-356-0006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: JACOB BRYCE THATCHER
Title or Position: DO
Credential:
Phone: 208-356-0004