Healthcare Provider Details

I. General information

NPI: 1275276131
Provider Name (Legal Business Name): TYLER MICHAEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 N 4TH ST
OAKLAND MD
21550-1375
US

IV. Provider business mailing address

13806 OLEANDER DR SW
CUMBERLAND MD
21502-5934
US

V. Phone/Fax

Practice location:
  • Phone: 301-533-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0008990
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: