Healthcare Provider Details

I. General information

NPI: 1124308473
Provider Name (Legal Business Name): TYLER L ROBERTSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR SW
HUNTSVILLE AL
35801-6455
US

IV. Provider business mailing address

PO BOX 52404
LAFAYETTE LA
70505-2404
US

V. Phone/Fax

Practice location:
  • Phone: 256-429-5071
  • Fax: 256-429-4674
Mailing address:
  • Phone: 256-429-5071
  • Fax: 256-429-4674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN16057
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN169321
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-113384
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: