MEDICARE: DR. TYLER MARK STALL M.D.

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	208200000X	Plastic Surgery Physician	0101260329	VA
2	390200000X	Student in an Organized Health Care Education/Training Program	9407434	KS

General Provider Information

NPI Number	:	1831410828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TYLER MARK STALL M.D.

Provider Business Mailing Address
First Line	:	2510 GASKINS RD
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23238-1481
Country	:	US
Telephone Number	:	757-897-4843
Fax Number	:

Provider Business Practice Location Address
First Line	:	2510 GASKINS RD
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23238-1481
Country	:	US
Telephone Number	:	757-897-4843
Fax Number	:

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

Provider Enumeration Date	:	06/14/2010
Last Update Date	:	11/28/2016

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