Provider Demographics
NPI:1679833131
Name:MANSON, TYLER (DPM)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:
Last Name:MANSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 ASTER ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4164
Mailing Address - Country:US
Mailing Address - Phone:503-409-2657
Mailing Address - Fax:
Practice Address - Street 1:2235 MISSION ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1298
Practice Address - Country:US
Practice Address - Phone:503-581-2505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005573213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005573Medicaid
ILF400250518Medicare PIN