Basic Information
| Provider Information | |||||||||
| NPI: | 1710484589 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANNARD | ||||||||
| FirstName: | TYLER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5323 HARRY HINES BLVD STE E4.300 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753907208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146487207 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6201 HARRY HINES BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753901838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146483916 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2018 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0101271426 | VA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | S4572 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0101271426 | 05 | VA | MEDICAID |