Provider Demographics
NPI:1407397730
Name:BROCKMAN, TYLER F (DO)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:F
Last Name:BROCKMAN
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:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0550
Mailing Address - Country:US
Mailing Address - Phone:479-463-7775
Mailing Address - Fax:479-463-7187
Practice Address - Street 1:3 E. APPLEBY RD
Practice Address - Street 2:SUITE 301
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-404-1200
Practice Address - Fax:479-404-1201
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2028207Q00000X
NE390200000X
ARE-13314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program