Healthcare Provider Details

I. General information

NPI: 1639902679
Provider Name (Legal Business Name): TYLER PEMBERTON PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 W 10TH PL STE 100
MESA AZ
85201-3499
US

IV. Provider business mailing address

5226 S DREXEL
MESA AZ
85212-8511
US

V. Phone/Fax

Practice location:
  • Phone: 602-258-6797
  • Fax: 602-254-2636
Mailing address:
  • Phone: 602-258-6797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number313307
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: