Provider Demographics
NPI:1609545078
Name:WALTER, TYLER JOHN (CRNP)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JOHN
Last Name:WALTER
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 HAMEL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-2621
Mailing Address - Country:US
Mailing Address - Phone:630-639-1590
Mailing Address - Fax:
Practice Address - Street 1:100 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:484-476-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN661619163WC0200X
PASP024405363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine