MEDICARE: TYLER PETERSON DO INC

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	261QU0200X	Urgent Care Clinic/Center
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1437938297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TYLER PETERSON DO INC

Provider Business Mailing Address
First Line	:	2229 BARTON AVE
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-3411
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2229 BARTON AVE
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-3411
Country	:	US
Telephone Number	:	530-539-4781
Fax Number	:	530-238-6403

Authorized Official
Title or Position	:	MD/OWNER
Name	:	TYLER PETERSON
Credential	:
Telephone Number	:	281-602-5959

Provider Enumeration Date	:	09/21/2023
Last Update Date	:	03/20/2024

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Directions to “TYLER PETERSON DO INC ” Practice Location

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