Healthcare Provider Details

I. General information

NPI: 1609480631
Provider Name (Legal Business Name): TYLER FAULKNER LAT, ATC, CES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 MAGNOLIA CIR BLDG 1465
TYNDALL AFB FL
32403-5604
US

IV. Provider business mailing address

340 MAGNOLIA CIR BLDG 1465
TYNDALL AFB FL
32403-5604
US

V. Phone/Fax

Practice location:
  • Phone: 850-283-8298
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA0001405
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: