Provider Demographics
NPI:1790436640
Name:JOHNSON, TYLER (DC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4925 SE SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3850
Mailing Address - Country:US
Mailing Address - Phone:814-882-2328
Mailing Address - Fax:
Practice Address - Street 1:815 NE HALSEY ST STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1219
Practice Address - Country:US
Practice Address - Phone:814-882-2328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor