Basic Information
| Provider Information | |||||||||
| NPI: | 1740245968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFERSON | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | CAMERON | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2535 W OAK ST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762012331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403821577 | ||||||||
| FaxNumber: | 9403875471 | ||||||||
| Practice Location | |||||||||
| Address1: | 2535 W OAK ST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762012331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403821577 | ||||||||
| FaxNumber: | 9403875471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 05/23/2013 | ||||||||
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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 | 363AM0700X | PA06754 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA06754 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 825N93 | 01 | TX | BCBS TEXAS | OTHER | 835N03 | 01 | TX | BCBS TX 02/01/2011 | OTHER | P00954312 | 01 | TX | RAILROAD MEDICARE | OTHER | 1740245968 | 01 | NPI | OTHER | TXB120919 | 01 | TX | MEDICARE PART B - EFFECT 02/01/2011 | OTHER |