Provider Demographics
NPI:1407119563
Name:SELLERS, TYLER R (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:R
Last Name:SELLERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 REMIT
Mailing Address - Street 2:SUITE 1122
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-1122
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:231-922-4030
Practice Address - Street 1:335 GLESSNER AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2269
Practice Address - Country:US
Practice Address - Phone:419-526-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003526363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant