Provider Demographics
NPI:1730938697
Name:PINKHAM, TYLER EDWARD
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:EDWARD
Last Name:PINKHAM
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:PO BOX 471
Mailing Address - Street 2:
Mailing Address - City:NORTH ANSON
Mailing Address - State:ME
Mailing Address - Zip Code:04958-0471
Mailing Address - Country:US
Mailing Address - Phone:207-612-6832
Mailing Address - Fax:
Practice Address - Street 1:344 LAKEWOOD RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:ME
Practice Address - Zip Code:04950-3015
Practice Address - Country:US
Practice Address - Phone:207-474-2994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP241273363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily