Provider Demographics
NPI:1629704671
Name:TYLER, CHAD (PA-C)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:TYLER
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 1:1023 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SWEET HOME
Mailing Address - State:OR
Mailing Address - Zip Code:97386-1515
Mailing Address - Country:US
Mailing Address - Phone:541-255-1234
Mailing Address - Fax:877-414-2298
Practice Address - Street 1:1023 MAIN ST
Practice Address - Street 2:
Practice Address - City:SWEET HOME
Practice Address - State:OR
Practice Address - Zip Code:97386-1515
Practice Address - Country:US
Practice Address - Phone:541-255-1234
Practice Address - Fax:877-414-2298
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-30
Last Update Date:2023-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA214235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty