Provider Demographics
NPI:1609313352
Name:NOVOTNEY, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:NOVOTNEY
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 1:15059 N SCOTTSDALE RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-2379
Mailing Address - Country:US
Mailing Address - Phone:602-778-3600
Mailing Address - Fax:602-778-3602
Practice Address - Street 1:320 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1900
Practice Address - Country:US
Practice Address - Phone:276-666-7394
Practice Address - Fax:276-666-7866
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-005627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant