Provider Demographics
NPI:1073551347
Name:STANLEY, TYLER W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:W
Last Name:STANLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 LYNDON ST
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-5164
Mailing Address - Country:US
Mailing Address - Phone:562-230-4465
Mailing Address - Fax:
Practice Address - Street 1:233 LYNDON ST
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-5164
Practice Address - Country:US
Practice Address - Phone:562-230-4465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17829363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17829Medicaid
CAWPA17829EMedicare PIN
CAWPA17829AMedicare Oscar/Certification
CAWPA17829CMedicare PIN
CAWPA17829DMedicare PIN
CAQ27756Medicare UPIN