Provider Demographics
NPI:1164136552
Name:WILLIAMS, TYLOR
Entity Type:Individual
Prefix:
First Name:TYLOR
Middle Name:
Last Name:WILLIAMS
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:PSC BOX 20073
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:28542-0073
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3D MARINE RAIDER BATTALION
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:28542-0073
Practice Address - Country:US
Practice Address - Phone:910-440-1947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman