Provider Demographics
NPI:1033777677
Name:LOOMER, TYLER E (DO)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:E
Last Name:LOOMER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-9000
Mailing Address - Fax:
Practice Address - Street 1:775 PRAIRIE CENTER DR STE 300
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7317
Practice Address - Country:US
Practice Address - Phone:952-428-0300
Practice Address - Fax:952-428-0150
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2023-10-16
Deactivation Date:2020-04-08
Deactivation Code:
Reactivation Date:2020-04-29
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN70201207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program