Provider Demographics
NPI:1114379575
Name:IRVIN, TYLER (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:IRVIN
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 GETTYS ST
Mailing Address - Street 2:
Mailing Address - City:GETTYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17325-2534
Mailing Address - Country:US
Mailing Address - Phone:717-337-4197
Mailing Address - Fax:717-337-4121
Practice Address - Street 1:2060 CARLISLE RD
Practice Address - Street 2:
Practice Address - City:ASPERS
Practice Address - State:PA
Practice Address - Zip Code:17304-9707
Practice Address - Country:US
Practice Address - Phone:717-339-2580
Practice Address - Fax:717-677-4452
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0051412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer