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General NPI Number Information
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NPI Number | 1033641154
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Entity Type | Individual
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Provider Name | TYLER JUE NP
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Gender | Male
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Dates
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Enumeration Date | 03/29/2017
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Last Update Date | 02/05/2024
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Provider Practice Location Address
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Address Line | 645 E 5TH ST
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City | WEISER
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State | ID
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Zip | 83672-2202
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Country | US
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Telephone | 208-549-0370
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Fax | 208-302-0855
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Provider Business Mailing Address
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Address Line | 645 E 5TH ST
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City | WEISER
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State | ID
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Zip | 83672-2202
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Country | US
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Telephone |
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Fax | 208-302-0855
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 55104
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 55104
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License Number State | ID
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