Provider Demographics
NPI:1073023792
Name:HANSON, TYLER (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:HANSON
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18415 CUB CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-8339
Mailing Address - Country:US
Mailing Address - Phone:219-973-8033
Mailing Address - Fax:
Practice Address - Street 1:120 HARDWOOD DR
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-5030
Practice Address - Country:US
Practice Address - Phone:570-556-4191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-08
Last Update Date:2017-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0066912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer