=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427735323
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER C CHEATHAM FNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2023
-----------------------------------------------------
Last Update Date | 07/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 S 20TH AVE
-----------------------------------------------------
City | SAFFORD
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85546-3301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-428-3122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 526 HERITAGE CIR
-----------------------------------------------------
City | PIMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85543-0286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-835-5342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 219570
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------