Provider Demographics
NPI:1336521079
Name:HOLT, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:HOLT
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 1:827 LAMAR ALEXANDER PKWY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804
Mailing Address - Country:US
Mailing Address - Phone:865-984-0900
Mailing Address - Fax:865-984-1035
Practice Address - Street 1:827 LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804
Practice Address - Country:US
Practice Address - Phone:865-984-0900
Practice Address - Fax:865-984-1035
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2771363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6047756OtherBLUECROSS BLUESHIELD
TNQ019368Medicaid
TNQ019368Medicaid