Provider Demographics
NPI:1023901840
Name:GRAYSON, TYLER (NP)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:GRAYSON
Suffix:
Gender:X
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 WILSHIRE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1782
Mailing Address - Country:US
Mailing Address - Phone:310-854-6102
Mailing Address - Fax:
Practice Address - Street 1:11600 WILSHIRE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1782
Practice Address - Country:US
Practice Address - Phone:310-854-6102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95034894363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner