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General NPI Number Information
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NPI Number | 1356123863
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Entity Type | Individual
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Provider Name | TYSON DARRELL GREENER PA-C
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Gender | Male
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Dates
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Enumeration Date | 10/18/2023
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Last Update Date | 02/07/2025
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Provider Practice Location Address
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Address Line | 260 E 5TH ST N
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City | BURLEY
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State | ID
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Zip | 83318-3453
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Country | US
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Telephone | 208-678-9760
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Fax | 208-678-9758
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Provider Business Mailing Address
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Address Line | 684 E 400 N
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City | RUPERT
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State | ID
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Zip | 83350-9460
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Country | US
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Telephone | 208-670-7008
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Fax |
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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 | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 6571244
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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