Provider Demographics
NPI:1447299789
Name:TYLER, LAWRENCE R (PA-C)
Entity type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:R
Last Name:TYLER
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1400
Mailing Address - Fax:239-424-1421
Practice Address - Street 1:1815 HENSON AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1510
Practice Address - Country:US
Practice Address - Phone:269-492-6500
Practice Address - Fax:269-492-6461
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108308363AS0400X
OH50-00-0236363AS0400X
MI5601007215363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1447299789Medicaid
S57915Medicare UPIN