Provider Demographics
NPI:1083297287
Name:MCCHANE, JESSE TYLER (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:TYLER
Last Name:MCCHANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-461-7149
Mailing Address - Fax:208-467-3391
Practice Address - Street 1:207 1ST ST S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3703
Practice Address - Country:US
Practice Address - Phone:208-466-7869
Practice Address - Fax:208-466-5359
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-16990207Q00000X
IDMRM-2026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine