Provider Demographics
NPI:1255979225
Name:LACOSTE, TYLER JAMES (PA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:LACOSTE
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 1:2472 RIDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35244-1251
Mailing Address - Country:US
Mailing Address - Phone:985-518-2345
Mailing Address - Fax:
Practice Address - Street 1:777 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4597
Practice Address - Country:US
Practice Address - Phone:303-436-4949
Practice Address - Fax:303-602-5184
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1543363AM0700X
COPA.0007592363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical