Provider Demographics
NPI:1881999639
Name:THORNOCK, TYLER REX (CRNA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:REX
Last Name:THORNOCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15250 S. MOUNTAIN RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338
Mailing Address - Country:US
Mailing Address - Phone:435-668-4334
Mailing Address - Fax:
Practice Address - Street 1:15205 S. MOUNTAIN RIDGE CT
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99338
Practice Address - Country:US
Practice Address - Phone:435-668-4334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60203414367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered