Provider Demographics
NPI:1831460922
Name:WITMER, TYLER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:
Last Name:WITMER
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 1:109B E ELLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1794
Mailing Address - Country:US
Mailing Address - Phone:503-437-3594
Mailing Address - Fax:503-623-3398
Practice Address - Street 1:2316 VALLEY PARK DR
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-4428
Practice Address - Country:US
Practice Address - Phone:319-239-5832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002262363A00000X
ORPA182471363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant