Provider Demographics
NPI:1275276131
Name:MICHAEL, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:MICHAEL
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 1:13806 OLEANDER DR SW
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-5934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 N 4TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1375
Practice Address - Country:US
Practice Address - Phone:301-533-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDC0008990363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program