Provider Demographics
NPI:1952337560
Name:TYLER, ROY NANDO (CSA)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:NANDO
Last Name:TYLER
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 SCOTTSVILLE RD
Mailing Address - Street 2:B2 PMB 137
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3376
Mailing Address - Country:US
Mailing Address - Phone:270-782-0434
Mailing Address - Fax:
Practice Address - Street 1:1945 SCOTTSVILLE RD
Practice Address - Street 2:B2 PMB 137
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3376
Practice Address - Country:US
Practice Address - Phone:270-782-0434
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA066363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000212655OtherANTHEM
KY58221859-COtherHUMANA