Provider Demographics
NPI:1902644966
Name:SAMPLES, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:SAMPLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 S GLENWOOD PL
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-2208
Mailing Address - Country:US
Mailing Address - Phone:773-828-9537
Mailing Address - Fax:
Practice Address - Street 1:11600 ELDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:LAKE VIEW TERRACE
Practice Address - State:CA
Practice Address - Zip Code:91342-6506
Practice Address - Country:US
Practice Address - Phone:405-805-1828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program