Provider Demographics
NPI:1699170688
Name:THORPE, TYSON (PA-C)
Entity type:Individual
Prefix:MR
First Name:TYSON
Middle Name:
Last Name:THORPE
Suffix:
Gender:M
Credentials:PA-C
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 3648
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-2522
Mailing Address - Country:US
Mailing Address - Phone:208-620-5210
Mailing Address - Fax:
Practice Address - Street 1:1130 W PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8780
Practice Address - Country:US
Practice Address - Phone:208-209-0288
Practice Address - Fax:208-209-0289
Is Sole Proprietor?:No
Enumeration Date:2014-11-03
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004137363AM0700X
IDPA-1423363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical