Provider Demographics
NPI:1912724782
Name:MCKENNON, TYLER (PTA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:MCKENNON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3309 56TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-8580
Mailing Address - Country:US
Mailing Address - Phone:360-564-2220
Mailing Address - Fax:
Practice Address - Street 1:3309 56TH ST STE 102
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-8580
Practice Address - Country:US
Practice Address - Phone:253-564-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP161047132225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant