Provider Demographics
NPI:1871206789
Name:PYBURN, MARK THOMAS (NP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:PYBURN
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:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:
Practice Address - Street 1:867 S VANGUARD WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7552
Practice Address - Country:US
Practice Address - Phone:208-302-7950
Practice Address - Fax:208-302-7955
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID74921363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner