Provider Demographics
NPI:1720731623
Name:GLENDRANGE, TYLER MASON (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:MASON
Last Name:GLENDRANGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6905 HARRIS AVE, KAILUA, HI 96734
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734
Mailing Address - Country:US
Mailing Address - Phone:808-257-3365
Mailing Address - Fax:
Practice Address - Street 1:6905 HARRIS AVE
Practice Address - Street 2:BLDG. 6905
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-257-3365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101279636208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice