Provider Demographics
NPI:1306200753
Name:TYNER, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:TYNER
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 1:285 MCREYNOLDS DR
Mailing Address - Street 2:
Mailing Address - City:ANGWIN
Mailing Address - State:CA
Mailing Address - Zip Code:94508-9746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:285 MCREYNOLDS DR
Practice Address - Street 2:
Practice Address - City:ANGWIN
Practice Address - State:CA
Practice Address - Zip Code:94508-9746
Practice Address - Country:US
Practice Address - Phone:828-808-3068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251822251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics