MEDICARE: TYLER PERRY PA-C, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	14176484-1206	UT
2	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1730675851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER PERRY PA-C, ATC

Provider Business Mailing Address
First Line	:	1831 E 3170 S
Second Line	:
City	:	MILLCREEK
State	:	UT
Zip	:	84106-3776
Country	:	US
Telephone Number	:	404-820-3570
Fax Number	:

Provider Business Practice Location Address
First Line	:	12846 3600 W
Second Line	:
City	:	RIVERTON
State	:	UT
Zip	:	84065
Country	:	US
Telephone Number	:	404-820-3570
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2018
Last Update Date	:	05/05/2026

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