Provider Demographics
NPI:1215618764
Name:THACKER, TYLER BLAKE (CRNA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:BLAKE
Last Name:THACKER
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 1:269 G B SANDERS DR
Mailing Address - Street 2:
Mailing Address - City:ASHVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35953-3018
Mailing Address - Country:US
Mailing Address - Phone:256-630-9778
Mailing Address - Fax:
Practice Address - Street 1:1802 6TH AVE S # NP7401-C
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1932
Practice Address - Country:US
Practice Address - Phone:205-975-3737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-134728367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered