Provider Demographics
NPI:1407205875
Name:WALDRON, TYLER GRANT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:GRANT
Last Name:WALDRON
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
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Mailing Address - Street 1:26401 CROWN VALLEY PKWY
Mailing Address - Street 2:STE 101
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6302
Mailing Address - Country:US
Mailing Address - Phone:949-348-4000
Mailing Address - Fax:949-348-7466
Practice Address - Street 1:26401 CROWN VALLEY PKWY
Practice Address - Street 2:STE 101
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6302
Practice Address - Country:US
Practice Address - Phone:949-348-4000
Practice Address - Fax:949-348-7466
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA53447363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical