Basic Information
| Provider Information | |||||||||
| NPI: | 1992759674 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA TYLER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TYLER HOME CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 240 WILLOW ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561781166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072475521 | ||||||||
| FaxNumber: | 5072475972 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 WILLOW ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561781166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072475521 | ||||||||
| FaxNumber: | 5072475972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ST. AUBIN | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 5075379161 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AVERA TYLER | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | MN | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 599245100 | 05 | MN | MEDICAID | 1889ATY | 01 | MN | BLUE CROSS | OTHER |