Basic Information
| Provider Information | |||||||||
| NPI: | 1588244008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2140 OAKFORD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191464315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096052795 | ||||||||
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| Practice Location | |||||||||
| Address1: | 925 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2673393738 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2021 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | PA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.