MEDICARE: TYLER J D'HULST 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	7437974-1206	UT

General Provider Information

NPI Number	:	1386876530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER J D'HULST PA-C

Provider Business Mailing Address
First Line	:	4650 HARRISON BLVD
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84403-4303
Country	:	US
Telephone Number	:	801-475-3481
Fax Number	:	801-475-3414

Provider Business Practice Location Address
First Line	:	6112 S 1550 E
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84405-5007
Country	:	US
Telephone Number	:	801-475-3800
Fax Number	:	801-475-3801

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

Provider Enumeration Date	:	08/20/2009
Last Update Date	:	02/05/2015

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