Provider Demographics
NPI:1225830185
Name:STATEN, CHRISTOPHER TYLER
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:TYLER
Last Name:STATEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:TY
Other - Middle Name:
Other - Last Name:STATEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1394 DUNLAWTON AVE APT 308
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4760
Mailing Address - Country:US
Mailing Address - Phone:304-962-8953
Mailing Address - Fax:304-962-8953
Practice Address - Street 1:1394 DUNLAWTON AVE APT 308
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4760
Practice Address - Country:US
Practice Address - Phone:304-962-8953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI46436390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program