Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | OT-2206 | ID |
NPI | 1053926816 |
---|---|
Provider Name | Tyler James Holloway |
First Address | Nampa, ID 83687-5509 |
Second Address | Nampa, ID 83687-5509 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/09/2020 |
Last Update Date | 09/09/2020 |