Individual
TYLER ROE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
1344 HILAND AVE STE A, BURLEY, ID 83318
(208) 678-7246
Mailing address
1344 HILAND AVE STE A, BURLEY, ID 83318-1564
(208) 678-7246
(208) 678-5833
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Q8621
TX
207LP2900X
Pain Medicine (Anesthesiology) Physician
Primary
O-1201
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
388203701
—
TX
01
—
388203702
CSHCN
TX
Enumeration date
04/06/2014
Last updated
04/13/2022
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