Healthcare Provider Details

I. General information

NPI: 1689172868
Provider Name (Legal Business Name): TYLER ELLIOTT DIAL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

923 W 3RD ST
PEMBROKE NC
28372-9628
US

IV. Provider business mailing address

2002 N CEDAR ST STE B
LUMBERTON NC
28358-3926
US

V. Phone/Fax

Practice location:
  • Phone: 910-521-0564
  • Fax: 910-521-8091
Mailing address:
  • Phone: 910-272-3048
  • Fax: 910-738-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-07818
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: