Provider Demographics
NPI:1346400785
Name:TYER, NICOLE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:TYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E 61ST ST FL 12
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-8722
Mailing Address - Country:US
Mailing Address - Phone:310-890-5565
Mailing Address - Fax:
Practice Address - Street 1:8635 W 3RD ST STE 295W
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6166
Practice Address - Country:US
Practice Address - Phone:310-385-3518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA107790207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine