Healthcare Provider Details

I. General information

NPI: 1699392381
Provider Name (Legal Business Name): TYLER PATRICK ELLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21907 64TH AVE W STE 100
MOUNTLAKE TERRACE WA
98043-2298
US

IV. Provider business mailing address

21907 64TH AVE W STE 100
MOUNTLAKE TERRACE WA
98043-2298
US

V. Phone/Fax

Practice location:
  • Phone: 206-880-7333
  • Fax: 206-880-7367
Mailing address:
  • Phone: 206-880-7333
  • Fax: 206-880-7367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number14278
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberLD61240013
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberLD61240013
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: