Provider Demographics
NPI:1740225978
Name:TYERMAN, GAYLE HOLDERNESS (MD)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:HOLDERNESS
Last Name:TYERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 CYPRESS ST STE D
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5411
Mailing Address - Country:US
Mailing Address - Phone:707-964-5696
Mailing Address - Fax:
Practice Address - Street 1:510 CYPRESS ST STE D
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5411
Practice Address - Country:US
Practice Address - Phone:707-357-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43243208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3116OtherCCS