Provider Demographics
NPI:1902258585
Name:DICK, TYLER ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TYLER
Middle Name:ELIZABETH
Last Name:DICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:TYLER
Other - Middle Name:ELIZABETH
Other - Last Name:THAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:995 LONGSPUR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-2560
Mailing Address - Country:US
Mailing Address - Phone:248-860-8353
Mailing Address - Fax:
Practice Address - Street 1:555 W 14 MILE RD
Practice Address - Street 2:
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017-3100
Practice Address - Country:US
Practice Address - Phone:248-655-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009828363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant