Provider Demographics
NPI:1679040505
Name:ANDRADE, TYLER ROSS
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ROSS
Last Name:ANDRADE
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 1:3970 SHIMMERING PLAINS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-4822
Mailing Address - Country:US
Mailing Address - Phone:857-880-7165
Mailing Address - Fax:
Practice Address - Street 1:3970 SHIMMERING PLAINS ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-4822
Practice Address - Country:US
Practice Address - Phone:857-880-7165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV00002289986Medicaid