Healthcare Provider Details

I. General information

NPI: 1730755323
Provider Name (Legal Business Name): TYLER PARENT MARTIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 FRIST BLVD STE 102
FORT PIERCE FL
34950-4838
US

IV. Provider business mailing address

2006 13TH ST
VERO BEACH FL
32960-3777
US

V. Phone/Fax

Practice location:
  • Phone: 772-465-4651
  • Fax:
Mailing address:
  • Phone: 772-453-4803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9114555
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMPA.5748PA
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: