Healthcare Provider Details

I. General information

NPI: 1124977632
Provider Name (Legal Business Name): TYLER PEARSON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2026
Last Update Date: 01/27/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 MOORESFIELD RD
WAKEFIELD RI
02879-2045
US

IV. Provider business mailing address

1061 MOORESFIELD RD
WAKEFIELD RI
02879-2045
US

V. Phone/Fax

Practice location:
  • Phone: 401-302-0420
  • Fax:
Mailing address:
  • Phone: 401-302-0420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNA
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: