Provider Demographics
NPI:1447590401
Name:BAGLEY, TYLER JAMES (CRNA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 W VIA DE PALMAS
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-7381
Mailing Address - Country:US
Mailing Address - Phone:530-868-7509
Mailing Address - Fax:
Practice Address - Street 1:661 W VIA DE PALMAS
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-7381
Practice Address - Country:US
Practice Address - Phone:530-868-7509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000079367500000X
AZ249724367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ249724OtherARIZONA