Provider Demographics
NPI:1801372974
Name:HUDSON, TYLER (MAT, LAT, ATC, CEIS)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:HUDSON
Suffix:
Gender:M
Credentials:MAT, LAT, ATC, CEIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 STADIUM MALL DRIVE
Mailing Address - Street 2:HAMP B292
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47907
Mailing Address - Country:US
Mailing Address - Phone:317-800-5137
Mailing Address - Fax:
Practice Address - Street 1:550 STADIUM MALL DRIVE
Practice Address - Street 2:HAMP
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907
Practice Address - Country:US
Practice Address - Phone:317-800-5137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002994A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer