Healthcare Provider Details

I. General information

NPI: 1376357467
Provider Name (Legal Business Name): TYLER ROGERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2025
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 CLIFTON RD NE
ATLANTA GA
30322-4201
US

IV. Provider business mailing address

1182 BROOKHAVEN PARK PL NE
BROOKHAVEN GA
30319-4560
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-7980
  • Fax:
Mailing address:
  • Phone: 217-419-5846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN307444
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN-CRNA307444
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: