Provider Demographics
NPI:1760059612
Name:MEMMOTT, TYLER NATHAN (CRNA)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:NATHAN
Last Name:MEMMOTT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5324 42ND STREET
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601
Mailing Address - Country:US
Mailing Address - Phone:435-660-0451
Mailing Address - Fax:
Practice Address - Street 1:1766 W 800 S
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-5516
Practice Address - Country:US
Practice Address - Phone:435-623-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101640367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered