Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | O-1272 | ID |
Y | 111NI0900X | Internist | O-1272 | ID |
NPI | 1003278730 |
---|---|
Provider Name | Tyler T Birch |
First Address | Boise, ID 83702-4501 |
Second Address | Meridian, ID 83642-6352 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2016 |
Last Update Date | 09/04/2020 |