Provider Demographics
NPI:1851704407
Name:TYNER, JERRY L
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:TYNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17350 MOUNT HERRMANN ST STE A
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4114
Mailing Address - Country:US
Mailing Address - Phone:714-444-3463
Mailing Address - Fax:714-444-1768
Practice Address - Street 1:17350 MOUNT HERRMANN ST STE A
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4114
Practice Address - Country:US
Practice Address - Phone:714-444-3463
Practice Address - Fax:714-444-1768
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22360390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program