Provider Demographics
NPI:1043842289
Name:SHEA, TYLER MICHAEL (LMT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:MICHAEL
Last Name:SHEA
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PIER 1 STE 308
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-6338
Mailing Address - Country:US
Mailing Address - Phone:503-974-0914
Mailing Address - Fax:
Practice Address - Street 1:10 PIER 1 STE 308
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-6338
Practice Address - Country:US
Practice Address - Phone:503-974-0914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK138924225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist