Provider Demographics
NPI:1831668342
Name:JAMISON, TYLER LEE (ATC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:LEE
Last Name:JAMISON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4651
Mailing Address - Country:US
Mailing Address - Phone:207-592-5580
Mailing Address - Fax:
Practice Address - Street 1:925 UNION ST STE 3
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3051
Practice Address - Country:US
Practice Address - Phone:207-974-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT6622080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine