MEDICARE: MR. TYLER W. STANLEY PA-C

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	PA17829	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073551347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TYLER W. STANLEY PA-C

Provider Business Mailing Address
First Line	:	233 LYNDON ST
Second Line	:
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-5164
Country	:	US
Telephone Number	:	562-230-4465
Fax Number	:

Provider Business Practice Location Address
First Line	:	233 LYNDON ST
Second Line	:
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-5164
Country	:	US
Telephone Number	:	562-230-4465
Fax Number	:

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

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/11/2008

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