Provider Demographics
NPI:1417708223
Name:HARRELSON, TYLER (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:HARRELSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:TYLER
Other - Middle Name:DANIEL
Other - Last Name:HARRELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 419052
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-9052
Mailing Address - Country:US
Mailing Address - Phone:314-851-1000
Mailing Address - Fax:
Practice Address - Street 1:416 OLD SMIZER MILL RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-3553
Practice Address - Country:US
Practice Address - Phone:314-467-1590
Practice Address - Fax:314-275-4655
Is Sole Proprietor?:No
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024002456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant