Provider Demographics
NPI:1174386841
Name:VITUS, TYLER ANTHONY (PA-C)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:ANTHONY
Last Name:VITUS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 PLANTED PINE DR
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-5518
Mailing Address - Country:US
Mailing Address - Phone:330-717-1736
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-2567
Practice Address - Country:US
Practice Address - Phone:216-444-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00778207PE0004X
OH50.009387RX207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services