Provider Demographics
NPI:1356609127
Name:CRISP, TYLER ALLEN (DO)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:ALLEN
Last Name:CRISP
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5887
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71307-5887
Mailing Address - Country:US
Mailing Address - Phone:318-442-5399
Mailing Address - Fax:318-442-1586
Practice Address - Street 1:1444 PETERMAN DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3432
Practice Address - Country:US
Practice Address - Phone:318-442-5399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR2898207L00000X
LA301690207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2424050Medicaid
LA504605YMSLMedicare PIN