Provider Demographics
NPI:1700217494
Name:GREEN, TYLER DOUGLAS (CNP)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:DOUGLAS
Last Name:GREEN
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 SCHATZ POINTE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3856
Mailing Address - Country:US
Mailing Address - Phone:937-438-9841
Mailing Address - Fax:937-438-9851
Practice Address - Street 1:7901 SCHATZ POINTE DR
Practice Address - Street 2:SUITE A
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-3856
Practice Address - Country:US
Practice Address - Phone:937-438-9841
Practice Address - Fax:937-438-9851
Is Sole Proprietor?:No
Enumeration Date:2013-12-05
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.15402-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0097903Medicaid
OHP01397437Medicare PIN
OH0097903Medicaid