Provider Demographics
NPI:1174117212
Name:SHADE, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:SHADE
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 1:905 LINNEY LN
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28152-6411
Mailing Address - Country:US
Mailing Address - Phone:980-339-0927
Mailing Address - Fax:
Practice Address - Street 1:905 LINNEY LN # A
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28152-6411
Practice Address - Country:US
Practice Address - Phone:980-339-0927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer