Provider Demographics
NPI:1477980449
Name:BACHRODT, TYLER ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ELIZABETH
Last Name:BACHRODT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 N BRIGHTLEAF BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-4405
Mailing Address - Country:US
Mailing Address - Phone:919-791-2040
Mailing Address - Fax:
Practice Address - Street 1:507 N BRIGHTLEAF BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577
Practice Address - Country:US
Practice Address - Phone:919-791-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006972363A00000X
GA2574363A00000X
NC0010-08060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant