Provider Demographics
NPI:1467940478
Name:KNUTSON, TYLER MICHAEL (DC, CSCS)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:MICHAEL
Last Name:KNUTSON
Suffix:
Gender:M
Credentials:DC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10973 104TH PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-2826
Mailing Address - Country:US
Mailing Address - Phone:763-567-8082
Mailing Address - Fax:
Practice Address - Street 1:1421 E WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391
Practice Address - Country:US
Practice Address - Phone:952-473-9637
Practice Address - Fax:952-473-1851
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6472111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor