Healthcare Provider Details

I. General information

NPI: 1801530191
Provider Name (Legal Business Name): TYLER NORTHRUP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2022
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 WENDELL AVE
LEWISTOWN MT
59457-2261
US

IV. Provider business mailing address

408 WENDELL AVE
LEWISTOWN MT
59457-2261
US

V. Phone/Fax

Practice location:
  • Phone: 406-535-7711
  • Fax:
Mailing address:
  • Phone: 406-535-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMED-PHYS-LIC-174119
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: