Healthcare Provider Details

I. General information

NPI: 1114379690
Provider Name (Legal Business Name): TYLER MARSHALL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 08/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W MAPLE ST
FARMINGTON NM
87401-5630
US

IV. Provider business mailing address

2204 IRONWOOD PL STE B
COEUR D ALENE ID
83814-2662
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6648
  • Fax: 505-609-2259
Mailing address:
  • Phone: 505-609-2258
  • Fax: 505-609-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA-01419
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: