Basic Information
| Provider Information | |||||||||
| NPI: | 1972031979 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TROTTER | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | WADE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3709 VANILLA NUT PL UNIT 2 | ||||||||
| Address2: | |||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890842274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406429981 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 323 N MARYLAND PKWY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891013130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023853330 | ||||||||
| FaxNumber: | 7022077119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2017 | ||||||||
| LastUpdateDate: | 06/02/2017 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.