Healthcare Provider Details

I. General information

NPI: 1346894409
Provider Name (Legal Business Name): TYLER RICHARD DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2019
Last Update Date: 07/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 E RIVERSIDE DR STE 302
SAINT GEORGE UT
84790-8722
US

IV. Provider business mailing address

617 E RIVERSIDE DR STE 302
SAINT GEORGE UT
84790-8722
US

V. Phone/Fax

Practice location:
  • Phone: 435-652-6024
  • Fax:
Mailing address:
  • Phone: 435-652-6024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9009540-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: