Provider Demographics
NPI:1538892419
Name:CUMMINGS, TYLER DOUGLAS (PA-C)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:DOUGLAS
Last Name:CUMMINGS
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 1:3165 STONEBRIDGE CT APT 10
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4731
Mailing Address - Country:US
Mailing Address - Phone:269-270-5515
Mailing Address - Fax:
Practice Address - Street 1:601 JOHN ST STE M-401
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5353
Practice Address - Country:US
Practice Address - Phone:855-618-2676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5601011444363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program