Provider Demographics
NPI:1588443311
Name:DETWILER, TYLER SCOTT (CRNA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:SCOTT
Last Name:DETWILER
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 1:29553 N 69TH LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-3183
Mailing Address - Country:US
Mailing Address - Phone:309-532-3864
Mailing Address - Fax:
Practice Address - Street 1:3929 E BELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2112
Practice Address - Country:US
Practice Address - Phone:602-923-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ297985367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered