=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760910848
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER TUNNELL ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2017
-----------------------------------------------------
Last Update Date | 06/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | JAMES WILSON CENTER 333 BEN WEINER DRIVE
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-865-5511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11010 LOCUST DR
-----------------------------------------------------
City | DAMASCUS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20872-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 304660
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------