Provider Demographics
NPI:1043077340
Name:HOLST, TYLER WILLIAM
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:WILLIAM
Last Name:HOLST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4949 W LA PUENTA AVE
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-3176
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4949 W LA PUENTA AVE
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-3176
Practice Address - Country:US
Practice Address - Phone:503-931-7902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ284601163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant