Provider Demographics
NPI:1124471446
Name:ANDERSON, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:ANDERSON
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 1:407 DUNN BLVD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:575 COAL VALLEY RD STE 504
Practice Address - Street 2:
Practice Address - City:CLAIRTON
Practice Address - State:PA
Practice Address - Zip Code:15025-3729
Practice Address - Country:US
Practice Address - Phone:412-267-6810
Practice Address - Fax:412-267-6817
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058264363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant