Provider Demographics
NPI:1467062695
Name:TUSTIN, TYLER WAYNE
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:WAYNE
Last Name:TUSTIN
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 1:28345 OLD TARBY RD
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-7167
Mailing Address - Country:US
Mailing Address - Phone:918-413-5113
Mailing Address - Fax:
Practice Address - Street 1:1501 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2574
Practice Address - Country:US
Practice Address - Phone:479-226-3409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR3382225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist