Provider Demographics
NPI:1790279685
Name:GALE, TYLER JOHN (FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:JOHN
Last Name:GALE
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9733 E THEIA DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-8524
Mailing Address - Country:US
Mailing Address - Phone:602-350-1853
Mailing Address - Fax:
Practice Address - Street 1:7219 N LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:LUKE AFB
Practice Address - State:AZ
Practice Address - Zip Code:85309-1529
Practice Address - Country:US
Practice Address - Phone:623-856-6713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11410363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty