Provider Demographics
NPI:1497472591
Name:RUSSELL, TYLER EDWARD (APRN)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:EDWARD
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 S JONES BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-5605
Mailing Address - Country:US
Mailing Address - Phone:702-350-1477
Mailing Address - Fax:
Practice Address - Street 1:2725 S JONES BLVD STE 109
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5605
Practice Address - Country:US
Practice Address - Phone:702-350-1477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-20
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV817329363L00000X, 363L00000X
OR202111331RN163W00000X
WARN60979252163W00000X
WAAP61440563363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse