Provider Demographics
NPI:1083466189
Name:BROWN, TYLER ADAM
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ADAM
Last Name:BROWN
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 1:428 SUMMER VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:OK
Mailing Address - Zip Code:73010-3142
Mailing Address - Country:US
Mailing Address - Phone:806-205-1353
Mailing Address - Fax:
Practice Address - Street 1:428 SUMMER VALLEY RD
Practice Address - Street 2:
Practice Address - City:BLANCHARD
Practice Address - State:OK
Practice Address - Zip Code:73010-3142
Practice Address - Country:US
Practice Address - Phone:806-205-1353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program