Provider Demographics
NPI:1912090408
Name:TYLER, MICHAEL C (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:TYLER
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 1:65 N MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-1000
Mailing Address - Country:US
Mailing Address - Phone:801-585-6526
Mailing Address - Fax:
Practice Address - Street 1:65 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-1000
Practice Address - Country:US
Practice Address - Phone:801-585-6526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT178754-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT93863OtherGEM
UT28749OtherPEHP
UT293655OtherDMBA
UTQMXAF01875OtherALTIUS
UT870542403 84121 A002OtherTRICARE
UTPRA01321OtherMOLINA
UT107001187102OtherIHC
UT93863OtherGEM