Provider Demographics
NPI:1447085766
Name:TATHWELL, TRACY A (PT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:TATHWELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2736 W PEAR APPLE ST
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-4753
Mailing Address - Country:US
Mailing Address - Phone:208-376-7548
Mailing Address - Fax:
Practice Address - Street 1:3277 E LOUISE DR STE 410
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9360
Practice Address - Country:US
Practice Address - Phone:208-489-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist