Provider Demographics
NPI:1730868019
Name:PASSMORE, TYLER SHAWN (PA-C)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:SHAWN
Last Name:PASSMORE
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 1:145 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1462
Mailing Address - Country:US
Mailing Address - Phone:814-375-4045
Mailing Address - Fax:814-375-4041
Practice Address - Street 1:145 HOSPITAL AVE STE 212
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1461
Practice Address - Country:US
Practice Address - Phone:814-375-4045
Practice Address - Fax:814-375-4041
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064608363A00000X
PAOA006515363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant