Provider Demographics
NPI:1912739152
Name:TYLER, JOHNNIE RAY III (PTA)
Entity type:Individual
Prefix:MR
First Name:JOHNNIE
Middle Name:RAY
Last Name:TYLER
Suffix:III
Gender:M
Credentials:PTA
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Other - First Name:
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Mailing Address - Street 1:3946 BULVERDE PKWY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-2257
Mailing Address - Country:US
Mailing Address - Phone:210-313-0422
Mailing Address - Fax:
Practice Address - Street 1:3100 SCHOFIELD RD
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-7577
Practice Address - Country:US
Practice Address - Phone:210-808-2226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2057090225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant