Provider Demographics
NPI:1861561094
Name:PRYOR, THOMAS ERNEST (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ERNEST
Last Name:PRYOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 5TH AVE WEST
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330
Mailing Address - Country:US
Mailing Address - Phone:208-934-4800
Mailing Address - Fax:208-934-9611
Practice Address - Street 1:121 5TH AVE WEST
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330
Practice Address - Country:US
Practice Address - Phone:208-934-4800
Practice Address - Fax:208-934-9611
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7337207Q00000X
MO2011020656207Q00000X
TN46233207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805049900Medicaid
G26653Medicare UPIN
ID1140438Medicare ID - Type Unspecified