Basic Information
| Provider Information | |||||||||
| NPI: | 1255311288 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBB | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | DOUGLASS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631374 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 NE MOTHER JOSEPH PL | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986643200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604255131 | ||||||||
| FaxNumber: | 3604255509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | MD00034512 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | MD00034512 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0402006 | 01 | WA | L&I-SEATTLE RADIOLOGY | OTHER | 150946 | 05 | OR | MEDICAID | 0383458 | 01 | WA | L&I-RADIA VANCOUVER | OTHER | 0422055 | 01 | WA | L&I-SWEDISH RADIA EDMONDS | OTHER | 0383459 | 01 | WA | L&I-RADIA SEATTLE | OTHER | 0422056 | 01 | WA | L&I-EVERGREEN RADIA | OTHER | 0415512 | 01 | WA | L&I-SOUTH SOUND RADIOLOGY | OTHER | 1005976 | 05 | WA | MEDICAID |