Provider Demographics
NPI:1902582471
Name:ELLIOTT, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:EL CAMINO REAL S, BLDG 4101
Mailing Address - Street 2:CAMP PENDLETON
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:92058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:EL CAMINO REAL S, BLDG 4101
Practice Address - Street 2:CAMP PENDLETON
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:92058
Practice Address - Country:US
Practice Address - Phone:760-725-8912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman