Provider Demographics
NPI:1336649409
Name:WICKETT, TYLER REN (ATC)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:REN
Last Name:WICKETT
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 MEYLAND HALL
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-5391
Mailing Address - Country:US
Mailing Address - Phone:360-593-1714
Mailing Address - Fax:
Practice Address - Street 1:1401 PRESQUE ISLE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2818
Practice Address - Country:US
Practice Address - Phone:360-593-1714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010017552255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer