Provider Demographics
NPI:1326699745
Name:SOUTHERN, TYLER ALEXANDER (PA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:ALEXANDER
Last Name:SOUTHERN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-893-3180
Mailing Address - Fax:336-893-3189
Practice Address - Street 1:152 E KINDERTON WAY STE 101
Practice Address - Street 2:
Practice Address - City:BERMUDA RUN
Practice Address - State:NC
Practice Address - Zip Code:27006-7351
Practice Address - Country:US
Practice Address - Phone:336-893-3180
Practice Address - Fax:336-893-3189
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-11440363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant