Provider Demographics
NPI:1841051463
Name:WILLIAMS, TYLER JAMES LAROY (PHYSICIAN ASSOCIATE)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES LAROY
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6524 MARSH RD
Mailing Address - Street 2:
Mailing Address - City:KINGSLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49649-9625
Mailing Address - Country:US
Mailing Address - Phone:989-388-8364
Mailing Address - Fax:
Practice Address - Street 1:400 HOBART ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2331
Practice Address - Country:US
Practice Address - Phone:989-388-8364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012256363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant