Individual
TANNER BLAYLOCK BODILY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
3360 WASHINGTON PKWY STE 1, IDAHO FALLS, ID 83404-8333
(208) 524-3416
Mailing address
630 TROY AVE, IDAHO FALLS, ID 83402-2906
(208) 680-7929
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
ID
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
09/18/2020
Last updated
10/04/2021
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