Provider Demographics
NPI:1285294835
Name:MCCAULEY, TYLER J (PA-C)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:MCCAULEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 W 69TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-1147
Mailing Address - Country:US
Mailing Address - Phone:773-483-5011
Mailing Address - Fax:
Practice Address - Street 1:1135 W 69TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-1147
Practice Address - Country:US
Practice Address - Phone:773-483-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007108363AM0700X
IL085-007108363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical