Healthcare Provider Details

I. General information

NPI: 1811043862
Provider Name (Legal Business Name): BRYCE DAVID WYLIE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 E MAIN ST STE 1
SAINT ANTHONY ID
83445-1546
US

IV. Provider business mailing address

PO BOX 18
SAINT ANTHONY ID
83445-0018
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-4900
  • Fax: 208-624-4116
Mailing address:
  • Phone: 208-356-4900
  • Fax: 208-624-4112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1013
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: