Provider Demographics
NPI:1962640805
Name:GREEN, TYLER (PT,DPT)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2668 E CITIZENS DR
Mailing Address - Street 2:STE 5
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4796
Mailing Address - Country:US
Mailing Address - Phone:479-747-0014
Mailing Address - Fax:844-809-1417
Practice Address - Street 1:2668 E CITIZENS DR
Practice Address - Street 2:SUITE 5
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4796
Practice Address - Country:US
Practice Address - Phone:479-747-0014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3447225100000X
MS4871225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist