Healthcare Provider Details

I. General information

NPI: 1477033884
Provider Name (Legal Business Name): TYLAR BISSELL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 SE 16TH AVE
OCALA FL
34471-4656
US

IV. Provider business mailing address

4500 W NEWBERRY RD
GAINESVILLE FL
32607-2245
US

V. Phone/Fax

Practice location:
  • Phone: 352-620-1900
  • Fax:
Mailing address:
  • Phone: 352-336-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111429
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: