Provider Demographics
NPI:1598846495
Name:DETWILER, TYSON D (DC)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:D
Last Name:DETWILER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 MEADOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-8826
Mailing Address - Country:US
Mailing Address - Phone:620-218-9451
Mailing Address - Fax:
Practice Address - Street 1:4210 MEADOWBROOK LN
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-8826
Practice Address - Country:US
Practice Address - Phone:620-218-9451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-4983111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS062239OtherBCBS OF KS PROVIDER #
KS062239OtherBCBS OF KS PROVIDER #