Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | G52123 | CA |
NPI | 1275612798 |
---|---|
Provider Name | Lafayette Michael Tylee |
First Address | Hesperiq, CA 92345-3914 |
Second Address | Victorville, CA 92395-3865 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2006 |
Last Update Date | 08/07/2007 |