Provider Demographics
NPI:1568921781
Name:UPPSTROM, TYLER JAMES
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:UPPSTROM
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 1:310 E 71ST ST APT 6B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 E 70TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021
Practice Address - Country:US
Practice Address - Phone:508-868-3506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program