Provider Demographics
NPI:1710577762
Name:TREVINO, TYLER (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:TREVINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DELBERT
Other - Middle Name:T
Other - Last Name:TREVINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:517 N TORNILLO ST APT A
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-2752
Mailing Address - Country:US
Mailing Address - Phone:505-553-5191
Mailing Address - Fax:
Practice Address - Street 1:4615 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2702
Practice Address - Country:US
Practice Address - Phone:915-247-5999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171W00000XOther Service ProvidersContractor