Basic Information
Provider Information | |||||||||
NPI: | 1346757168 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TYLER | ||||||||
FirstName: | MARCIANA | ||||||||
MiddleName: | CASTILLO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSN AGNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2929 CALDER ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | BEAUMONT | ||||||||
State: | TX | ||||||||
PostalCode: | 777021841 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4098339797 | ||||||||
FaxNumber: | 4096546886 | ||||||||
Practice Location | |||||||||
Address1: | 137 N LHS DR STE B | ||||||||
Address2: |   | ||||||||
City: | LUMBERTON | ||||||||
State: | TX | ||||||||
PostalCode: | 776578620 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4098339797 | ||||||||
FaxNumber: | 4096546946 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/02/2018 | ||||||||
LastUpdateDate: | 09/19/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | AP134015 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
ID | Type | State | Issuer | Description | 381624101 | 05 | TX |   | MEDICAID |