Healthcare Provider Details

I. General information

NPI: 1831905124
Provider Name (Legal Business Name): TYLER THAI DINH LE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 LAKE COOK RD STE 280
DEERFIELD IL
60015-5255
US

IV. Provider business mailing address

707 LAKE COOK RD STE 280
DEERFIELD IL
60015-5255
US

V. Phone/Fax

Practice location:
  • Phone: 847-480-0004
  • Fax: 847-480-8707
Mailing address:
  • Phone: 847-480-0004
  • Fax: 847-480-8707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011055
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: