Healthcare Provider Details

I. General information

NPI: 1063949089
Provider Name (Legal Business Name): AVERA TYLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 E GEORGE ST
IVANHOE MN
56142-9707
US

IV. Provider business mailing address

300 S BRUCE ST
MARSHALL MN
56258-1934
US

V. Phone/Fax

Practice location:
  • Phone: 507-694-1414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE STREIER
Title or Position: CEO
Credential:
Phone: 507-537-9160