Provider Demographics
NPI:1902573405
Name:COOPER, TYLER JAMES (PT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:COOPER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-165 HUALALAI RD STE 100
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-3722
Mailing Address - Country:US
Mailing Address - Phone:808-329-0591
Mailing Address - Fax:
Practice Address - Street 1:75-165 HUALALAI RD STE 100
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-3722
Practice Address - Country:US
Practice Address - Phone:808-329-0591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2025-01-29
Deactivation Date:2025-01-23
Deactivation Code:
Reactivation Date:2025-01-29
Provider Licenses
StateLicense IDTaxonomies
HIPT-6095225100000X
AZRBT-21-181388106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician