Healthcare Provider Details

I. General information

NPI: 1700556982
Provider Name (Legal Business Name): TYLER WILLIAM DIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 MAMARONECK AVE STE 200
HARRISON NY
10528-2430
US

IV. Provider business mailing address

833 CHESTNUT ST STE 520
PHILADELPHIA PA
19107-4430
US

V. Phone/Fax

Practice location:
  • Phone: 888-636-7840
  • Fax:
Mailing address:
  • Phone: 267-606-4478
  • Fax: 267-339-3761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberNA
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number027626
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: