Basic Information
| Provider Information | |||||||||
| NPI: | 1669027967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARDILLO | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | JEFFREY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 960 LASSINO CT | ||||||||
| Address2: | |||||||||
| City: | PUNTA GORDA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339506524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9415056120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 620 S LEMAY AVE | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805243543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702215811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2019 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA0006776 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.