Provider Demographics
NPI:1124308473
Name:ROBERTSON, TYLER L (CRNA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:L
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 52404
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-2404
Mailing Address - Country:US
Mailing Address - Phone:256-429-5071
Mailing Address - Fax:256-429-4674
Practice Address - Street 1:1 HOSPITAL DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6455
Practice Address - Country:US
Practice Address - Phone:256-429-5071
Practice Address - Fax:256-429-4674
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN16057367500000X
TNRN169321163W00000X
AL1-113384367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4306609OtherBCBS OF TN
AL133589Medicaid
GA003114495AMedicaid
GA003114495AMedicaid