Provider Demographics
NPI:1235697301
Name:ISRAEL, TYLER JORDAN
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JORDAN
Last Name:ISRAEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13120 SW 92ND AVE PH 19
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-8707
Mailing Address - Country:US
Mailing Address - Phone:270-313-7347
Mailing Address - Fax:
Practice Address - Street 1:1200 BRECKENRIDGE ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1089
Practice Address - Country:US
Practice Address - Phone:270-683-8672
Practice Address - Fax:270-685-8233
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant