Provider Demographics
NPI:1780357228
Name:RODRIGUEZ LICHTENBERG, TYLER MATTHEW (NP)
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:MATTHEW
Last Name:RODRIGUEZ LICHTENBERG
Suffix:
Gender:M
Credentials:NP
Other - Prefix:MR
Other - First Name:TYLER
Other - Middle Name:MATTHEW
Other - Last Name:LICHTENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8954 LANTANA RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-6112
Mailing Address - Country:US
Mailing Address - Phone:561-434-4776
Mailing Address - Fax:561-434-5055
Practice Address - Street 1:8954 LANTANA RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-6112
Practice Address - Country:US
Practice Address - Phone:561-434-4776
Practice Address - Fax:561-434-5055
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11031941363LF0000X
FLRN9535382363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid