Healthcare Provider Details

I. General information

NPI: 1730675851
Provider Name (Legal Business Name): TYLER PERRY PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5126 W DAYBREAK PKWY
SOUTH JORDAN UT
84009-5994
US

IV. Provider business mailing address

1831 E 3170 S
MILLCREEK UT
84106-3776
US

V. Phone/Fax

Practice location:
  • Phone: 801-213-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14176484-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: