Provider Demographics
NPI:1639399611
Name:LANDGRAF, TYLER WRIGHT (MSED, ATC)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:WRIGHT
Last Name:LANDGRAF
Suffix:
Gender:M
Credentials:MSED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 S NATIONAL AVE
Mailing Address - Street 2:FORSYTHE RM 109
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65897-0027
Mailing Address - Country:US
Mailing Address - Phone:417-576-8009
Mailing Address - Fax:
Practice Address - Street 1:901 S NATIONAL AVE
Practice Address - Street 2:FORSYTHE RM 109
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65897-0027
Practice Address - Country:US
Practice Address - Phone:417-576-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090094312081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine