Basic Information
Provider Information | |||||||||
NPI: | 1093100752 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LADNER | ||||||||
FirstName: | TYLER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1028 WAKEFIELD PL | ||||||||
Address2: |   | ||||||||
City: | BRANDON | ||||||||
State: | MS | ||||||||
PostalCode: | 390477666 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2283431801 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 308 CORPORATE DR | ||||||||
Address2: |   | ||||||||
City: | RIDGELAND | ||||||||
State: | MS | ||||||||
PostalCode: | 391578803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6018987527 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2015 | ||||||||
LastUpdateDate: | 05/09/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | PA00243 | MS | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.