Healthcare Provider Details

I. General information

NPI: 1063900108
Provider Name (Legal Business Name): MR. TYLER EWING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 N STAR WAY
MODESTO CA
95356-9262
US

IV. Provider business mailing address

PO BOX 576768
MODESTO CA
95357-6768
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-1200
  • Fax:
Mailing address:
  • Phone: 209-577-1200
  • Fax: 209-577-6517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QH0600X
TaxonomyHistology Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: