Provider Demographics
NPI:1982330015
Name:ROBERTS, TYLER CHARLES (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:CHARLES
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 W 930 N
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-4104
Mailing Address - Country:US
Mailing Address - Phone:801-492-1999
Mailing Address - Fax:801-492-1991
Practice Address - Street 1:1912 W 930 N
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-4104
Practice Address - Country:US
Practice Address - Phone:801-492-1999
Practice Address - Fax:801-492-1991
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13565674-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant