MEDICARE: MR. TYLER ALAN CROSS PA-C

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	50.007810RX	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1199502	OTHER		NCCPA

General Provider Information

NPI Number	:	1770205973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TYLER ALAN CROSS PA-C

Provider Business Mailing Address
First Line	:	15721 MADISON AVE APT 1
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-5626
Country	:	US
Telephone Number	:	410-698-7596
Fax Number	:

Provider Business Practice Location Address
First Line	:	9500 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44195-5626
Country	:	US
Telephone Number	:	410-698-7596
Fax Number	:

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

Provider Enumeration Date	:	09/14/2022
Last Update Date	:	11/28/2022

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