Basic Information
| Provider Information | |||||||||
| NPI: | 1932417474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEHLKE | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 871 WOODSIDE LN E | ||||||||
| Address2: | #2 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958254345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304009697 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 N A ST | ||||||||
| Address2: | BUILDING A | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958110612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164401500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2010 | ||||||||
| LastUpdateDate: | 09/17/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.