Provider Demographics
NPI:1861955049
Name:LACY, TYLER CARLETON (MD)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:CARLETON
Last Name:LACY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5295 S COMMERCE DR STE 550
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4736
Mailing Address - Country:US
Mailing Address - Phone:801-313-4110
Mailing Address - Fax:
Practice Address - Street 1:5295 S COMMERCE DR STE 550
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4736
Practice Address - Country:US
Practice Address - Phone:801-313-4110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-13
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
UT14222027-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program