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General NPI Number Information
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NPI Number | 1730725151
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Entity Type | Individual
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Provider Name | TYLER JOHN HALSTEAD PA-C
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Gender | Male
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Dates
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Enumeration Date | 11/20/2019
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Last Update Date | 09/19/2022
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Provider Practice Location Address
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Address Line | 4111 1ST AVE STE 3
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City | NITRO
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State | WV
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Zip | 25143-1345
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Country | US
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Telephone | 304-755-4797
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Fax | 304-755-4799
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Provider Business Mailing Address
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Address Line | 4111 1ST AVE STE 3
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City | NITRO
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State | WV
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Zip | 25143-1345
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Country | US
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Telephone | 304-755-4797
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 826
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License Number State | WV
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