Provider Demographics
NPI:1477290567
Name:MACIAS, TYLER ANTHONY (RN)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ANTHONY
Last Name:MACIAS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 N MOUNTAIN AVE APT 25F
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4121
Mailing Address - Country:US
Mailing Address - Phone:626-755-7287
Mailing Address - Fax:
Practice Address - Street 1:1161 E COVINA BLVD
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1523
Practice Address - Country:US
Practice Address - Phone:626-859-5275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95137683163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse