Healthcare Provider Details

I. General information

NPI: 1982330015
Provider Name (Legal Business Name): TYLER CHARLES ROBERTS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 E 4500 S STE 200
MILLCREEK UT
84107-2797
US

IV. Provider business mailing address

495 E 4500 S STE 200
MILLCREEK UT
84107-2797
US

V. Phone/Fax

Practice location:
  • Phone: 801-595-8844
  • Fax:
Mailing address:
  • Phone: 801-595-8844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13565674-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: