Provider Demographics
NPI:1558712455
Name:LANDGREN, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:LANDGREN
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 1:5349 ADAMS AVE PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4736
Mailing Address - Country:US
Mailing Address - Phone:801-479-9865
Mailing Address - Fax:801-479-5846
Practice Address - Street 1:5349 ADAMS AVE PKWY STE A
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4736
Practice Address - Country:US
Practice Address - Phone:801-479-9865
Practice Address - Fax:801-479-5846
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9801160-24012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic