Provider Demographics
NPI:1730725151
Name:HALSTEAD, TYLER JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JOHN
Last Name:HALSTEAD
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 1:4111 1ST AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1345
Mailing Address - Country:US
Mailing Address - Phone:304-755-4797
Mailing Address - Fax:
Practice Address - Street 1:4111 1ST AVE STE 3
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1345
Practice Address - Country:US
Practice Address - Phone:304-755-4797
Practice Address - Fax:304-755-4799
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV826363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1730725151Medicaid