Provider Demographics
NPI:1922785856
Name:TABOADA, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:TABOADA
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 1:243 OMIRA DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-3633
Mailing Address - Country:US
Mailing Address - Phone:408-771-9649
Mailing Address - Fax:
Practice Address - Street 1:2295 PLUMMER AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-4767
Practice Address - Country:US
Practice Address - Phone:408-269-0701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302308225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist