Healthcare Provider Details

I. General information

NPI: 1659900736
Provider Name (Legal Business Name): TYLER AKIRA ICE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 E FLAMINGO AVE
NAMPA ID
83687-3138
US

IV. Provider business mailing address

928 S AUSTIN WAY
ANAHEIM CA
92808-2350
US

V. Phone/Fax

Practice location:
  • Phone: 714-318-0439
  • Fax:
Mailing address:
  • Phone: 714-318-0439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM-17236
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberM-17236
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: