Healthcare Provider Details

I. General information

NPI: 1003746660
Provider Name (Legal Business Name): TYLER PALMER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 S BRIDGE ST
SAINT ANTHONY ID
83445-2130
US

IV. Provider business mailing address

328 CUL DE SAC DR
REXBURG ID
83440-1429
US

V. Phone/Fax

Practice location:
  • Phone: 208-624-4008
  • Fax:
Mailing address:
  • Phone: 208-840-1950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-8958
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: