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General NPI Number Information
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NPI Number | 1679143812
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Entity Type | Individual
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Provider Name | TYLER JACK BRANHAM PA-C, ATC
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Gender | Male
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Dates
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Enumeration Date | 06/29/2021
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Last Update Date | 08/11/2021
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Provider Practice Location Address
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Address Line | 4110 22ND PL
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City | LUBBOCK
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State | TX
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Zip | 79410-1122
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Country | US
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Telephone | 806-792-4329
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Fax |
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Provider Business Mailing Address
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Address Line | 4903 75TH ST
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City | LUBBOCK
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State | TX
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Zip | 79424-2144
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Country | US
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Telephone | 806-241-9401
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT6761
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA14675
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License Number State | TX
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