Provider Demographics
NPI:1447286125
Name:THORNE, TRISTAN (DPT)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:THORNE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 E GENTRY WAY
Mailing Address - Street 2:STE 250
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3501
Mailing Address - Country:US
Mailing Address - Phone:208-888-0044
Mailing Address - Fax:
Practice Address - Street 1:3090 E GENTRY WAY
Practice Address - Street 2:STE 250
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3501
Practice Address - Country:US
Practice Address - Phone:208-888-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1975225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1652972Medicare ID - Type Unspecified