Provider Demographics
NPI:1700357845
Name:ANDERSON, TYLER JAMES
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:ANDERSON
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 1:39100 CONTRERAS RD STE D
Mailing Address - Street 2:
Mailing Address - City:ANZA
Mailing Address - State:CA
Mailing Address - Zip Code:92539-8724
Mailing Address - Country:US
Mailing Address - Phone:951-765-7142
Mailing Address - Fax:951-763-0495
Practice Address - Street 1:39100 CONTRERAS RD STE D
Practice Address - Street 2:
Practice Address - City:ANZA
Practice Address - State:CA
Practice Address - Zip Code:92539-8724
Practice Address - Country:US
Practice Address - Phone:951-765-7142
Practice Address - Fax:951-763-0495
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver