Healthcare Provider Details

I. General information

NPI: 1760643472
Provider Name (Legal Business Name): TYLER ADAM PEZALSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E PARK AVE
STATE COLLEGE PA
16803-6709
US

IV. Provider business mailing address

PO BOX 16
STATE COLLEGE PA
16804-0016
US

V. Phone/Fax

Practice location:
  • Phone: 814-231-7100
  • Fax:
Mailing address:
  • Phone: 814-466-5090
  • Fax: 814-466-5095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2012-02188
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101246832
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD457219
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1031202100001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: