Healthcare Provider Details

I. General information

NPI: 1588147458
Provider Name (Legal Business Name): TYLER HARRELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 MOUNTAIN VIEW DR
SANFORD NC
27332-1361
US

IV. Provider business mailing address

500 UNIVERSITY DR
HERSHEY PA
17033-2360
US

V. Phone/Fax

Practice location:
  • Phone: 910-578-1216
  • Fax:
Mailing address:
  • Phone: 800-243-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA067332
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: