=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013741321
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER ANTHONY GILL PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2024
-----------------------------------------------------
Last Update Date | 08/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 236 W JAMESTOWN RD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16125-9268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-988-9776
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 236 W JAMESTOWN RD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16125-9268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-988-9776
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------