Provider Demographics
NPI:1346421021
Name:BLACKWELDER, TYLER J (DPT)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:J
Last Name:BLACKWELDER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 W PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8459
Mailing Address - Country:US
Mailing Address - Phone:208-758-0484
Mailing Address - Fax:208-561-7242
Practice Address - Street 1:827 W PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8459
Practice Address - Country:US
Practice Address - Phone:208-819-8486
Practice Address - Fax:208-561-7242
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2507225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1652803OtherMEDICARE PROVIDER NUMBER
ID008105Medicaid