Healthcare Provider Details

I. General information

NPI: 1275090722
Provider Name (Legal Business Name): TYLER DAVIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SHADOW LN
LAS VEGAS NV
89106-4194
US

IV. Provider business mailing address

2020 PALOMINO LN STE 100
LAS VEGAS NV
89106-4894
US

V. Phone/Fax

Practice location:
  • Phone: 702-388-4000
  • Fax:
Mailing address:
  • Phone: 702-759-8600
  • Fax: 702-384-1815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberPA2084
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: