Healthcare Provider Details

I. General information

NPI: 1134834310
Provider Name (Legal Business Name): TYLER ELLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2023
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8767 WILSHIRE BLVD FL 2
BEVERLY HILLS CA
90211-2714
US

IV. Provider business mailing address

4140 W 190TH ST
TORRANCE CA
90504-5513
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-3333
  • Fax: 310-423-1300
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA64180
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: