Provider Demographics
NPI:1548682941
Name:STOOTS, TYLER JACK (PA-C)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JACK
Last Name:STOOTS
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 1:1950 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3763
Mailing Address - Country:US
Mailing Address - Phone:321-636-0005
Mailing Address - Fax:
Practice Address - Street 1:390 N COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3456
Practice Address - Country:US
Practice Address - Phone:321-633-3162
Practice Address - Fax:321-821-4955
Is Sole Proprietor?:No
Enumeration Date:2014-01-20
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9107491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant