Healthcare Provider Details

I. General information

NPI: 1457901530
Provider Name (Legal Business Name): TYLER JEFFREY MIZE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2019
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5575 E SR 44
WILDWOOD FL
34785-8282
US

IV. Provider business mailing address

2009 N LAKECREST LOOP
HERNANDO FL
34442-6259
US

V. Phone/Fax

Practice location:
  • Phone: 352-571-4418
  • Fax:
Mailing address:
  • Phone: 423-505-7540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112561
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: