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NPI Code Detail

MEDICARE: TYLER JACK STOOTS PA-C

MEDICARE: TYLER JACK STOOTS 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
1363A00000XPhysician AssistantPA 9107491FL

Other Identifiers

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

General Provider Information

NPI Number : 1548682941
Entity Type Code : Individual
Provider Name (Legal Business Name) : TYLER JACK STOOTS PA-C
Provider Business Mailing Address
First Line : 1950 US HIGHWAY 1
Second Line :
City : ROCKLEDGE
State : FL
Zip : 32955-3763
Country : US
Telephone Number : 321-636-0005
Fax Number :
Provider Business Practice Location Address
First Line : 390 N COURTENAY PKWY
Second Line :
City : MERRITT ISLAND
State : FL
Zip : 32953-3456
Country : US
Telephone Number : 321-633-3162
Fax Number : 321-821-4955
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/20/2014
Last Update Date : 02/09/2023

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