Basic Information
| Provider Information | |||||||||
| NPI: | 1134715071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUNDRIDGE | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2020 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | APRN.CNP.0028121 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 3015580 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | 3015580 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.