Provider Demographics
NPI:1255744017
Name:WILLIAMSON, TYLER (PA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 E 9400 S # 103
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-6237
Mailing Address - Country:US
Mailing Address - Phone:225-939-8180
Mailing Address - Fax:
Practice Address - Street 1:580 E 9400 S
Practice Address - Street 2:103
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-8407
Practice Address - Country:US
Practice Address - Phone:225-939-8180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT9066323-1206OtherDIVISION OF PROFESSIONAL LICENSING