Provider Demographics
NPI:1902221823
Name:GRANT, TYLER (DO)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:
Practice Address - Street 1:613 23RD ST STE 440
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2885
Practice Address - Country:US
Practice Address - Phone:606-329-2888
Practice Address - Fax:606-329-2890
Is Sole Proprietor?:No
Enumeration Date:2014-02-28
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04400208600000X, 208600000X
OH34.013095208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery