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General NPI Number Information
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NPI Number | 1831410828
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Entity Type | Individual
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Provider Name | TYLER MARK STALL M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/14/2010
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Last Update Date | 11/28/2016
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Provider Practice Location Address
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Address Line | 2510 GASKINS RD
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City | HENRICO
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State | VA
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Zip | 23238-1481
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Country | US
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Telephone | 757-897-4843
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Fax |
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Provider Business Mailing Address
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Address Line | 2510 GASKINS RD
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City | HENRICO
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State | VA
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Zip | 23238-1481
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Country | US
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Telephone | 757-897-4843
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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 | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 0101260329
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 9407434
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License Number State | KS
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