Healthcare Provider Details

I. General information

NPI: 1215392360
Provider Name (Legal Business Name): TYLER JOHN PREWETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2015
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 PAUL ST
HARRISONBURG VA
22801-3225
US

IV. Provider business mailing address

220 PAUL ST
HARRISONBURG VA
22801-3225
US

V. Phone/Fax

Practice location:
  • Phone: 540-421-8101
  • Fax:
Mailing address:
  • Phone: 540-421-8101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: