Healthcare Provider Details

I. General information

NPI: 1629464896
Provider Name (Legal Business Name): TYLER WAYNE FRASER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1244 PRIMACY PKWY
MEMPHIS TN
38119-0201
US

IV. Provider business mailing address

6077 PRIMACY PKWY STE 140
MEMPHIS TN
38119-5754
US

V. Phone/Fax

Practice location:
  • Phone: 901-767-8662
  • Fax: 901-767-8666
Mailing address:
  • Phone: 901-786-4198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number62663
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: