Provider Demographics
NPI:1679233134
Name:SMITHERSEN, TYSON (FNP)
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:SMITHERSEN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 CHANNING WAY STE 206
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7546
Mailing Address - Country:US
Mailing Address - Phone:208-529-2230
Mailing Address - Fax:208-561-8061
Practice Address - Street 1:3200 CHANNING WAY STE 206
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7546
Practice Address - Country:US
Practice Address - Phone:208-529-2230
Practice Address - Fax:208-561-8061
Is Sole Proprietor?:No
Enumeration Date:2021-12-26
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10808238-4405363LF0000X
ID2361278363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily