MEDICARE: MR. TYLER JOHNSON RODRIGUEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	12613	GA

General Provider Information

NPI Number	:	1063248201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TYLER JOHNSON RODRIGUEZ

Provider Business Mailing Address
First Line	:	982 MEMORIAL DR SE APT 516
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30316-4474
Country	:	US
Telephone Number	:	336-653-9493
Fax Number	:

Provider Business Practice Location Address
First Line	:	4480 N SHALLOWFORD RD STE 200
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30338-6410
Country	:	US
Telephone Number	:	336-653-9493
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2024
Last Update Date	:	01/06/2026

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Directions to “ MR. TYLER JOHNSON RODRIGUEZ ” Practice Location

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