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General NPI Number Information
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NPI Number | 1598239808
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Entity Type | Individual
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Provider Name | TYLER DAVID AGNEW
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Gender | Male
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Dates
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Enumeration Date | 01/20/2019
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Last Update Date | 02/04/2025
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Provider Practice Location Address
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Address Line | 3420 ILLINOIS ST
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City | GREAT LAKES
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State | IL
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Zip | 60088-3161
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Country | US
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Telephone | 847-688-6577
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Fax |
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Provider Business Mailing Address
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Address Line | 3420 ILLINOIS ST
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City | GREAT LAKES
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State | IL
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Zip | 60088-3161
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Country | US
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Telephone | 847-688-6577
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 0101270164
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0101270164
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License Number State | VA
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