Provider Demographics
NPI:1407224553
Name:DESMOND, TYLER ANDREW
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ANDREW
Last Name:DESMOND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 DEVONSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2100
Mailing Address - Country:US
Mailing Address - Phone:419-353-0078
Mailing Address - Fax:
Practice Address - Street 1:1610 STADIUM DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43403-4302
Practice Address - Country:US
Practice Address - Phone:419-372-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-07
Last Update Date:2015-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer