Provider Demographics
NPI:1114379690
Name:MARSHALL, TYLER (CRNA)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:2204 IRONWOOD PL
Mailing Address - Street 2:STE B
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2662
Mailing Address - Country:US
Mailing Address - Phone:505-609-2258
Mailing Address - Fax:505-609-2259
Practice Address - Street 1:801 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5630
Practice Address - Country:US
Practice Address - Phone:505-609-6648
Practice Address - Fax:505-609-2259
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMCRNA-01419367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered