Provider Demographics
NPI:1245271659
Name:TIRRELL, LAURA L (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:TIRRELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5189
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1880 JUDITH LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3185
Practice Address - Country:US
Practice Address - Phone:208-367-6910
Practice Address - Fax:208-367-6170
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5784207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003977200Medicaid
ID003977200Medicaid
ID1124792Medicare ID - Type Unspecified