Provider Demographics
NPI:1598428187
Name:LYNCH, TYLER MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:MICHAEL
Last Name:LYNCH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7337 S RUSTY DR APT A
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2105
Mailing Address - Country:US
Mailing Address - Phone:801-828-7252
Mailing Address - Fax:
Practice Address - Street 1:7337 S RUSTY DR APT A
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2105
Practice Address - Country:US
Practice Address - Phone:801-828-7252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11963227-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant