Basic Information
| Provider Information | |||||||||
| NPI: | 1104269000 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONWAY | ||||||||
| FirstName: | TYLER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 E TERRA COTTA AVE STE 125 | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600143650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154557143 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 OSBORNE RD NE STE 255 | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632362500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2013 | ||||||||
| LastUpdateDate: | 08/30/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 62134 | MN | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 036.147026 | IL | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.