Healthcare Provider Details

I. General information

NPI: 1245821941
Provider Name (Legal Business Name): TYLER J THOMPSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LEFEVRE RD
STERLING IL
61081-1279
US

IV. Provider business mailing address

100 E LEFEVRE RD
STERLING IL
61081-1279
US

V. Phone/Fax

Practice location:
  • Phone: 815-625-0400
  • Fax: 815-625-2747
Mailing address:
  • Phone: 815-625-0400
  • Fax: 815-625-2747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209022666
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: