Provider Demographics
NPI:1659834836
Name:COLESAR, MICHAEL TYLER
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TYLER
Last Name:COLESAR
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 1:1060 GAFFNEY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-5002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:688 6TH ST
Practice Address - Street 2:
Practice Address - City:FORT RICHARDSON
Practice Address - State:AK
Practice Address - Zip Code:99505
Practice Address - Country:US
Practice Address - Phone:541-399-1269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-13
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK195381207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty