=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184258311
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYSON FLOWER FNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2020
-----------------------------------------------------
Last Update Date | 09/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3295 W ELDER ST STE 117
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83705-4771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-992-4086
-----------------------------------------------------
Fax | 208-210-1936
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3295 W ELDER ST STE 117
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83705-4771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-992-4086
-----------------------------------------------------
Fax | 208-210-1936
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 53465
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------