Healthcare Provider Details

I. General information

NPI: 1821762840
Provider Name (Legal Business Name): TYLER J MILLHOUSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 BECKS WOODS DR STE 200
BEAR DE
19701-3852
US

IV. Provider business mailing address

600 S 43RD ST
PHILADELPHIA PA
19104-4418
US

V. Phone/Fax

Practice location:
  • Phone: 302-834-7676
  • Fax:
Mailing address:
  • Phone: 215-596-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0011982
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: