MEDICARE: TANNER BLAYLOCK BODILY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant		ID

General Provider Information

NPI Number	:	1356957039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANNER BLAYLOCK BODILY

Provider Business Mailing Address
First Line	:	630 TROY AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83402-2906
Country	:	US
Telephone Number	:	208-680-7929
Fax Number	:

Provider Business Practice Location Address
First Line	:	3360 WASHINGTON PKWY STE 1
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-8333
Country	:	US
Telephone Number	:	208-524-3416
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2020
Last Update Date	:	10/04/2021

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Directions to “ TANNER BLAYLOCK BODILY ” Practice Location

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