Healthcare Provider Details

I. General information

NPI: 1417708223
Provider Name (Legal Business Name): TYLER HARRELSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TYLER DANIEL HARRELSON PA-C

II. Dates (important events)

Enumeration Date: 03/29/2024
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 VETERANS MEMORIAL PKWY STE 300
SAINT CHARLES MO
63303-2106
US

IV. Provider business mailing address

PO BOX 419052
SAINT LOUIS MO
63141-9052
US

V. Phone/Fax

Practice location:
  • Phone: 636-669-2350
  • Fax:
Mailing address:
  • Phone: 314-851-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2024002456
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: