Provider Demographics
NPI:1063248201
Name:RODRIGUEZ, TYLER JOHNSON
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:JOHNSON
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:982 MEMORIAL DR SE APT 516
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-4474
Mailing Address - Country:US
Mailing Address - Phone:336-653-9493
Mailing Address - Fax:
Practice Address - Street 1:4480 N SHALLOWFORD RD STE 200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6410
Practice Address - Country:US
Practice Address - Phone:336-653-9493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program