Provider Demographics
NPI:1497557417
Name:GREGG, TY WALTER
Entity type:Individual
Prefix:
First Name:TY
Middle Name:WALTER
Last Name:GREGG
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 1:2213 BUCHANAN RD
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-4265
Mailing Address - Country:US
Mailing Address - Phone:707-712-5919
Mailing Address - Fax:
Practice Address - Street 1:2213 BUCHANAN RD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4265
Practice Address - Country:US
Practice Address - Phone:707-712-5919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-27
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty