Provider Demographics
NPI:1740245968
Name:JEFFERSON, TYLER CAMERON (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:CAMERON
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-2331
Mailing Address - Country:US
Mailing Address - Phone:940-382-1577
Mailing Address - Fax:940-387-5471
Practice Address - Street 1:2535 W OAK ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-2331
Practice Address - Country:US
Practice Address - Phone:940-382-1577
Practice Address - Fax:940-387-5471
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06754363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX825N93OtherBCBS TEXAS
TX835N03OtherBCBS TX 02/01/2011
TXP00954312OtherRAILROAD MEDICARE
1740245968OtherNPI
TXTXB120919OtherMEDICARE PART B - EFFECT 02/01/2011
TXTXB107213Medicare PIN
TXP00954312OtherRAILROAD MEDICARE