Provider Demographics
NPI:1588905699
Name:HARRIS, TYSON A (NP)
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:A
Last Name:HARRIS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1758
Mailing Address - Country:US
Mailing Address - Phone:208-239-8033
Mailing Address - Fax:208-785-9450
Practice Address - Street 1:98 POPLAR ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1758
Practice Address - Country:US
Practice Address - Phone:208-239-8033
Practice Address - Fax:208-785-9450
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60641080363LA2200X
IDNP-1272A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health