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General NPI Number Information
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NPI Number | 1316890270
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Entity Type | Organization
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Legal Business Name | IDAHO UROLOGY 1 PLLC
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Dates
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Enumeration Date | 02/19/2026
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Last Update Date | 02/19/2026
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Provider Practice Location Address
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Address Line | 30 MADISON PROFESSIONAL PARK
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City | REXBURG
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State | ID
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Zip | 83440-2058
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Country | US
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Telephone | 208-351-6363
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Fax |
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Provider Business Mailing Address
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Address Line | 1124 BARNEY DAIRY RD
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City | REXBURG
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State | ID
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Zip | 83440-3544
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Country | US
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Telephone | 208-351-6363
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Fax |
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Authorized Official
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Title or Position | SURGEON
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Name | JACOB THATCHER
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Credential | DO
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Telephone | 208-351-6363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number |
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License Number State |
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